Coring knife

ABSTRACT

A coring knife can be used to make a circular incision. The coring knife includes an abutment that is inserted into an initial slit through the heart wall. The abutment can be inserted into the slit while oriented in a direction that minimizes its insertion profile. After insertion, the abutment is reoriented by turning a key so that its abutment surface faces toward a circular cutting edge of the coring knife on the other side of the heart wall. The circular incision through the heart wall is made by pressing the circular cutting edge of the coring knife against the abutment.

CROSS-REFERENCE TO RELATED APPLICATION

This application claims the benefit of U.S. Provisional Application No.61/487,658 filed May 18, 2011, which is incorporated herein byreference.

BACKGROUND OF THE INVENTION

1. Field of the Invention

This invention relates to the field of heart assist devices and methods,devices and systems for the in vivo implantation of VADs and itsattachment to the heart.

2. Description of the Related Art

Heart assist devices are implantable devices that assist the heart incirculating blood in the body. A ventricular assist device (VAD) is anexample of a heart assist device that is used to assist one or bothventricles of the heart to circulate blood. For patients suffering fromheart failure, assisting the left ventricle with a VAD is more common.Currently, VADs are commonly used as a treatment option or a bridge totransplant for patients with heart failure.

The procedure to implant VADs carries many risks and side effects. Theimplantation procedure is invasive as surgeons need to access the heartdirectly by opening the chest with a sternotomy or a thoracotomy.Generally, a heart-lung bypass machine is used during the procedure, buta beating heart procedure may minimize side effects associated withusing a heart-lung bypass machine in such a major invasive surgery.However, a beating heart procedure can potentially lead to significantblood loss during the process of implanting the VAD if great care is notexercised.

While procedural related issues during the implantation process candirectly impact the success of the implantation, some of theseprocedural issues may also impact patients' recovery. When complicationsarise during the implantation process, the recovery time for these veryill patients can be extended. Procedural issues may result in majordetrimental side effects for patients, directly increasing the recoverytime. The recovery time and risk factors are often compounded by theoriginally poor health of the heart failure patient in need of the VAD.

A system and method for implanting a ventricular assist device without asternotomy is desired. Furthermore, a system and method for safelyimplanting a VAD without requiring heart-lung bypass is desired.Additionally, a system and method for implanting a ventricular assistdevice in a beating-heart procedure is desired.

SUMMARY OF THE INVENTION

Briefly and in general terms, the present invention is directed to acoring knife.

In aspects of the present invention, a coring knife comprises a coringblade, a coring abutment, a key socket, and a key. The coring bladeincludes a circular cutting edge. The coring abutment is located forwardof the cutting edge. The key socket is located to the rear of the coringblade and includes a bearing surface. The key is connected to the coringabutment, includes a key edge in contact with the bearing surface, andis configured to be moved relative the key socket. When key is movedrelative the key socket, the key edge slips against the bearing surfaceand the key pivots the coring abutment relative to the coring blade.

In other aspects, the coring knife further comprises a control armconnecting the coring abutment to the key. The control arm extendsthrough the coring blade and the key socket.

In other aspects, the key is configured to be twisted about a twistaxis. When the key is twisted, the key edge slips against the bearingsurface and the key pivots the coring abutment relative to the coringblade

In other aspects, when the key is twisted, the control arm moves along alongitudinal axis that is parallel to the twist axis.

In other aspects, the key includes a cylinder having an outer surfacethat terminates at the key edge.

In other aspects, the key edge is disposed within a rear cavity of thekey socket.

In other aspects, the key socket includes a forward cavity and a septumwall separating the forward cavity from the rear cavity, and the bearingsurface forms a side of the of the wall within the rear cavity.

In other aspects, the coring blade is mounted over a central shaftextending out of the forward cavity of the key socket, the coring bladeis configured to be rotated around the central shaft, and when thecoring blade is rotated, the coring blade moves toward the coringabutment.

In other aspects, the coring blade is carried on an internal sleeve. Theinternal sleeve is carried on a central shaft extending out of theforward cavity of the key socket. The internal sleeve is configured toslide relative the central shaft in a direction toward the coringabutment. The coring blade is configured to be rotate relative theinternal sleeve. When the coring blade is rotated, the coring blademoves toward the coring abutment.

In other aspects, the coring knife further comprises a coring knife caseconfigured to be moved away from the key socket. The coring blade ismovable into and out of the coring knife case.

In other aspects, the coring blade is configured to move out of thecoring knife case by rotating the coring blade relative to the coringknife case.

In other aspects, the coring knife further comprises an control sleeveattached to the coring blade, the control sleeve having a helical slotthat extends into the coring knife case. The coring knife case includesa guide peg that protrudes into the helical slot, and wherein rotationof the control sleeve causes the coring blade to move out of the coringknife case.

In other aspects, the coring knife further comprises an internal sleeveand a central shaft. The central shaft fixedly attached to the keysocket and extends into the internal sleeve. The internal sleeve carriesthe control sleeve, the coring blade, and the coring knife case. Theinternal sleeve is configured to be selectively positioned and locked atany one of a plurality of locations on the central shaft.

In aspects of the present invention, a coring knife comprises a coringblade, a coring abutment, and coring knife case, and a key. The coringblade includes a cylindrical wall defining a circular cutting edge and ahollow interior. The coring knife case contains the coring blade. Thecoring blade is configured to be extended out of the coring knife caseand toward the coring abutment. The key is coupled to the coringabutment by a control arm extending into the coring blade. The keydisposed within a key socket and configured to be rotated relative tothe key socket. When key is rotated relative the key socket, the keypulls the control arm in a manner that pivots the coring abutmentrelative to the coring blade.

In other aspects, the coring knife case includes a stop featureconfigured to fit in an alignment feature of a separate device foraligning the coring knife prior to extension of the coring blade out ofthe coring knife case.

In other aspects, the coring knife case is configured to be selectivelypositioned and locked at any one of a plurality of locations between thekey socket and the coring abutment prior to extension of the coringblade out of the coring knife case.

In other aspects, the coring knife further comprising a detent mechanismthat selectively locks and unlocks the coring knife case at any one ofthe plurality of locations between the key socket and the coringabutment.

In aspects of the present invention, a coring knife comprises a coringabutment, a key connected to the coring abutment, and a slide assemblydisposed between the key and the coring abutment. The slide assemblyincludes a coring blade with a circular cutting edge and a coring knifecase containing the coring blade. The coring blade is configured toextend out of the coring knife case. The coring knife case is configuredto be selectively positioned and locked at any one of a plurality oflocations between the key and the coring abutment prior to extension ofthe coring blade out of the coring knife case.

In other aspects, the coring knife case includes a stop featureconfigured to fit in an alignment feature of a separate device foraligning the coring knife prior to extension of the coring blade out ofthe coring knife case

In other aspects, the coring knife further comprises a detent mechanismthat selectively locks and unlocks the coring knife case at any one ofthe plurality of locations between the key and the coring abutment.

The features and advantages of the invention will be more readilyunderstood from the following detailed description which should be readin conjunction with the accompanying drawings.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 illustrates a variation of the ventricular assist system.

FIGS. 2 a and 2 b are perspective and sectional views of a variation ofthe attachment ring attached to the valvular structure.

FIG. 3 a is a perspective view of a variation of the attachment ring.

FIG. 3 b is a cross-sectional view of A-A of FIG. 3 a.

FIG. 4 a is a perspective view of a variation of the attachment ring.

FIG. 4 b is a cross-sectional view of FIG. 4 a.

FIG. 5 illustrates a variation of the clamp.

FIGS. 6 a and 6 b illustrate a variation of the clamp in opened andclosed configurations, respectively.

FIGS. 7 a and 7 b illustrate a variation of the clamp on the attachmentring with the clamp in opened and closed configurations, respectively.

FIG. 8 a illustrates a variation of the attachment ring attached to theinflow conduit.

FIG. 8 b is a perspective view of section B-B of FIG. 8 a.

FIG. 8 c is the variation of cross-section B-B of FIG. 8 a shown in FIG.8 b.

FIG. 9 a illustrates a variation of the attachment ring attached to theinflow conduit.

FIG. 9 b is a perspective view of section B′-B′ of FIG. 9 a.

FIG. 9 c is the variation of cross-section B′-B′ of FIG. 9 a shown inFIG. 9 b.

FIGS. 10 a and 10 b are a perspective views of a variation of thevalvular structure.

FIGS. 10 c-10 e are perspective views of a variation of section C-C.

FIGS. 11 a through 11 c are bottom perspective, top perspective, and topviews, respectively, of a variation of the valvular structure.

FIGS. 12 a and 12 b illustrate perspective and section views,respectively, of a variation of the valve in a closed configuration.

FIG. 12 c is a perspective view of the valve of FIGS. 12 a and 12 b inan open configuration.

FIGS. 13 a and 13 b are top perspective and bottom perspective views ofa variation of the valve in a closed configuration.

FIGS. 13 c and 13 d are top perspective views of the valve of FIGS. 13 aand 13 b in open configurations.

FIGS. 14 a and 14 b are top perspective and bottom perspective views ofa variation of the valve.

FIGS. 15 a and 15 b are top perspective and bottom perspective views ofa variation of the valve.

FIGS. 15 c through 15 e illustrate variations of miter valves.

FIG. 15 f illustrates a variation of a duckbill diaphragm valve.

FIGS. 16 a and 16 b illustrate open and closed configurations,respectively, of a variation of the valvular structure of section C-C.

FIGS. 17 a and 17 b illustrate open and closed configurations,respectively, of a variation of the valvular structure of section C-C.

FIGS. 18 a and 18 b are exploded and top views of a variation of thevalve.

FIGS. 19 a and 19 b are perspective and sectional views of a variationof the valve integrated with an attachment ring.

FIGS. 19 c and 19 d are perspective and sectional views of a variationof the valve integrated with an attachment ring.

FIG. 20 illustrates a variation of the attachment ring and an explodedview of a variation of the valvular structure.

FIG. 21 a is a top perspective view of a variation of the valve.

FIG. 21 b is a variation of cross-section D-D of the valve.

FIG. 21 c is a bottom perspective view of the valve of FIG. 21 a withthe diaphragm flap shown in see-through.

FIG. 22 is a sectional view of a variation of the valvular structure.

FIG. 23 illustrates a variation of the valvular structure with thehousing shown in see-through.

FIG. 24 illustrates a variation of the valvular structure with thehousing in see-through.

FIG. 25 is a sectional view of a variation of a method for attaching thevalvular structure to the attachment ring.

FIGS. 26 a and 26 b are sectional views of a variation of a method forattaching the valvular structure to the attachment ring.

FIGS. 27 a and 27 b illustrate a variation of the method process flowfor implanting a variation of the ventricular assist system.

FIGS. 28 a and 28 b illustrate variations of a method for accessing thetarget site.

FIG. 29 a illustrates a variation of the tunneler.

FIGS. 29 b and 29 c illustrate variations of the tunneler of FIG. 29 awith the bullet tip removed.

FIG. 30 a illustrates a variation of the tunneler.

FIG. 30 b illustrates the tunneler of FIG. 30 a with the outer sheathremoved from the tunneler shaft.

FIG. 31 illustrates a variation of the tunneler attached to the outflowconduit.

FIG. 32 illustrates a variation of inserting the outflow conduit in thetarget site.

FIG. 33 a through 33 c illustrate a variation of a method foranastomosing the aorta to the outflow conduit.

FIG. 34 a illustrates blood flow through the outflow conduit afteraortic anastomosis.

FIGS. 34 b through 34 d illustrate variations of methods for stanchingblood flow through the outflow conduit.

FIG. 35 illustrates a variation of a method of attaching the attachmentring to the apex of the heart.

FIGS. 36 a and 36 c are perspective and side views, respectively, of avariation of the coring knife.

FIGS. 36 b and 36 d are perspective and side views of a variation ofsection F-F of FIG. 36 a.

FIG. 36 e is a side view of a variation of section F-F of FIG. 36 a withthe coring blade in a retracted configuration.

FIGS. 37 a and 37 b are perspective and sectional views, respectively,of a variation of the coring knife.

FIGS. 37 c and 37 d are front views of the coring knife with the coringabutment in a rotated configuration, and the coring blade in an extendedconfiguration, respectively.

FIG. 38 illustrates a variation of the coring knife.

FIG. 39 a is a side view with the valvular structure shown in cut-away,of a variation of a method of using the coring knife with the valvularstructure.

FIG. 39 b is a perspective end view of FIG. 39 a.

FIGS. 40 a through 40 i illustrate a variation of a method for using avariation of the ventricular assist device system.

FIGS. 41 a through 41 d illustrate a variation of a method for coring.

FIGS. 42 a through 42 c illustrate a variation of inserting the inflowconduit through the attachment ring.

FIGS. 43 a and 43 b illustrate a variation of a method for stanchingblood flow through the pump outflow elbow and de-airing the pump.

FIG. 44 illustrates a variation of a method for de-airing theventricular assist device.

FIG. 45 illustrates a variation of attaching the pump to the outflowconduit.

FIGS. 46 a-46 d show an attachment ring, FIGS. 46 b and 46 d beingpartial cross-sectional sectional views.

FIGS. 47 a-47 c show an attachment ring, FIG. 47 a showing a flat sheetof material used for making the attachment ring.

FIGS. 48 a-48 d show an embodiment an attachment ring with an integralvalve.

FIGS. 49 a-49 d are perspective views of a clamp for use on anattachment ring, FIG. 49 d showing clamp closed on an attachment ring.

FIGS. 50 a and 50 b are plan and perspective views of a clamp for use onan attachment ring, showing ratcheting teeth for locking the clampclosed.

FIG. 51 is a plan view of a clamp for use on an attaching ring with onepair of teeth.

FIGS. 52 a-52 c are perspective and cross-sectional views of a slittingtool for making a linear incision in the heart, the linear incisionallow for a subsequent circular incision.

FIGS. 53 a-53 f are perspective and partial plan views of a coring knifefor making a circular incision in the heart.

FIG. 54 is a partial plan view of a portion of a coring knife, showing avariation on the coring knife casing.

FIG. 55 is a partial plan view of a portion of a coring knife, showing avariation on the coring knife abutment.

FIGS. 56 a-56 d are perspective views of a coring knife having anin-line grip configuration, showing a key within a key socket, the keyfor pivoting a coring abutment.

FIG. 57 is a perspective view of the key of FIGS. 56 a-56 d.

FIGS. 58 a and 58 b are a perspective and a perspective cut-away view ofthe key socket of FIGS. 56 a-56 d.

FIGS. 59 a and 59 b are elevation views of the coring knife of FIGS. 56a-56 d, showing parts within the key socket.

FIGS. 60 a-60 c are perspective and cross-sectional views of a slittingtool having a forward housing and a rear housing.

DETAILED DESCRIPTION

As used herein, any term of approximation such as, without limitation,near, about, approximately, substantially, essentially and the like meanthat the word or phrase modified by the term of approximation need notbe exactly that which is written but may vary from that writtendescription to some extent. The extent to which the description may varywill depend on how great a change can be instituted and have one ofordinary skill in the art recognize the modified version as still havingthe properties, characteristics and capabilities of the modified word orphrase. For example without limitation, something that is described as“substantially circular” in shape refers to a shape that is perfectlycircular and a shape that one skilled in the art would readily recognizeas being circular even though diameters measured at multiple locationson the circle are not exactly the same. As another non-limiting example,a first structure that is described as “substantially parallel” inreference to a second structure encompasses an orientation that isperfectly parallel and an orientation that one skilled in the art wouldreadily recognize as being parallel even though distances betweencorresponding locations on the two respective structures are not exactlythe same. In general, but with the preceding discussion in mind, anumerical value herein that is modified by a word of approximation mayvary from the stated value by ±15%, unless expressly stated otherwise.

Variations of a system and method for implanting a VAD during abeating-heart procedure are disclosed. The system can minimize orprevent blood loss from the heart during the system implantationprocedure, notably during the steps of coring a portion of theepicardial wall and insertion of the inflow conduit through theepicardial wall. The system can provide a fluid-tight seal around thesurgical tools used to access or come into contact with the internalfluid volume of the heart. Throughout this disclosure, one shouldappreciate that references made to VADs equally applies to all heartassist devices. Similarly, the system and surgical tools may apply to asimilar procedure of cannulation to other parts of the heart or of thecardiovascular system.

FIG. 1 illustrates a ventricular assist device (VAD) system 13 with apump 8. All locations described as proximal or distal, herein, arerelative to the location of the pump 8. The pump 8 can draw blood fromthe left ventricle, and deliver the blood to the aorta at a higherpressure to assist the pumping of the heart. The pump 8 is configured todirect blood flow from one location (e.g., the heart) to a secondlocation (e.g., target vasculature like an aorta) in the vascular systemto provide mechanical circulatory support/assistance. For example, thepump 8 can be configured as a unidirectional turbine pump 8 to directblood from the inflow side of the pump 8 (e.g., from the heart) to theoutflow side of the pump 8 (e.g., to the aorta). A percutaneous lead 5having insulated wires can be used for transmission and/or receiving ofdata and/or power between the pump 8 and a controller and/or a remotedevice for controlling the operation of the pump 8. In one variation, acontroller or remote is outside of the patient's body. The pump 8 canhave any configuration including but not limited to having axial flow orcentrifugal flow.

The pump 8 can be directly attached to or have an inflow conduit 10 at afirst end of the pump 8 and directly attached to or have an outflowconduit 2 at a second end of the pump 8. The inflow conduit 10 can becoupled with the pump 8 by a helically threaded coupler configured toattach to the inflow port 7 of the pump 8.

The inflow conduit 10 can have a hollow channel for fluid communicationsuch as directing blood from a first location (e.g., the heart) to thepump 8. In one variation, the inflow conduit 10 can be flexible. Inanother variation, the inflow conduit 10 can be rigid, such as a metaltube. In yet another variation, the inflow conduit 10 may have acombination of rigid and flexible elements such as having a proximal(relative to the pump 8) rigid elbow for coupling with the pump 8 thatis connected to a flexible middle portion to accommodate for bending anda distal rigid portion (relative to the pump 8) for coupling with theheart. The inflow conduit may also be formed by a portion of the pumpbody.

As illustrated in FIG. 1, the inflow conduit 10 has a distal end thatcan be placed through the valvular structure 12 and the attachment ring22 before entering into the heart after implantation. A flexible middleportion of the inflow conduit 10 provides strain relief between thedistal end and the proximal end. The proximal end is coupled with thepump 8. Blood can enter the inflow conduit 10 through its distalopening, travel along the length of the inflow conduit 10, and enter thepump 8 at the inflow port 7 of the pump 8 after exiting the proximalopening of the inflow conduit 10. The inflow conduit 10 can be integralwith, or separate and attachable to, the pump 8.

The valvular structure 12 is configured to prevent or minimize bloodloss from the heart during the implantation of the VAD. The valvularstructure 12 can be removed from the system and the patient once theinflow conduit 10 is properly positioned relative to the heart, forexample, after the inflow conduit 10 has been inserted into theattachment ring 22. The valvular structure 12 can seal against a coringknife and/or the inflow conduit 10 which passes through a channelthrough the valvular structure 12. The valvular structure 12 canminimize or prevent blood flow out from the heart during theimplantation of the VAD. Additionally the valvular structure 12 canprovide for passage of other instruments during the procedure whilepreventing blood loss out of the heart.

The valvular structure 12 can be directly attached to an attachment ring22, for example, indirectly attaching the valvular structure 12 to theapex of the heart during use. The attachment ring 22 can be configuredto connect to a ventricle. The attachment ring 22 can fix and sealagainst the inflow conduit 10 once the VAD is implanted. The attachmentring 22 can be a ventricle or heart connector. The attachment ring 22can fixedly attach to the VAD to the wall of the heart. Thus, theattachment ring 22 is configured to be secured against the heart, and isalso configured to be secured against the inflow conduit 10.

An outflow conduit is coupled to the second end (e.g., outflow port) ofthe pump 8 where the blood or fluid exits the pump 8. In an axial flowpump arrangement, the outflow conduit 2 is approximately linear andopposite to the inflow conduit 10. Similar to the inflow conduit 10, aproximal end (relative to the pump 8) of the outflow conduit 2 iscoupled to the pump 8, whereas the distal end (relative to the pump 8)of the outflow conduit 2 is for coupling to a target vasculature (e.g.,aorta) where blood re-enters the circulatory system after exiting thepump 8.

Similar also to the inflow conduit 10, the proximal end of the outflowconduit 2 can be rigid for coupling to the pump 8. The middle portion ofthe outflow conduit 2 can be made from a flexible material for bendrelief. In one variation, the distal portion of the outflow conduit 2(relative to the pump 8) can be a flexible sealed graft that can be sewnonto a target vasculature (e.g., aorta) by way of an anastomosis, forblood to re-enter the circulatory system.

The ventricular assist system can have fluid communication between theinflow port 7, the inflow conduit 10, the pump 8, the outflow conduit 2and the outflow port. The components of the ventricular assist systemshown in FIG. 1, except for the valvular structure 12, can all orpartially be from a Heartmate II Left Ventricular Assist Device (fromThoratec Corporation, Pleasanton, Calif.).

FIGS. 2 a and 2 b illustrate a valvular structure 12. In conjunctionwith other components in a system, this valvular structure 12 helps toprevent or otherwise minimize blood loss out of the heart during theimplantation or cannulation procedure, for example, when an opening iscreated in the heart while the heart is beating, or when a heart-lungby-pass machine is not used. The valvular structure 12 has a housing 18that can be substantially cylindrical with a valve 16 and/or one or moreseals 17 coupled to the inside wall of the structure. The valve 16 canact as either a complete or a partial seal for the valvular structure12. The valve 16 can allow the flow of fluid or entry of an element in adistal direction and substantially impair or completely prevent the flowof fluid or entry of an element in a proximal direction. The housing 18and valve 16 can be configured to be attachable to and removable fromthe attachment ring 22. The housing 18 can be separatable and removablefrom the valve 16. The housing 18 can have an attachment ring channel 14around the inner circumference of the housing 18. The attachment ring 22can be positioned inside of the attachment ring channel 14 and at ornear one end of the housing 18. The attachment ring 22 and valvularstructure 12 can have longitudinal axes 187. The longitudinal axis ofthe attachment ring 22 and the longitudinal axis of the valvularstructure 12 can be co-axial.

A de-airing channel 15 can be configured through the wall of the housing18. In the process of cannulation or implantation, air can be introducedinto the valvular structure 12. Air entering the circulatory system cancause air embolism and can be harmful to a patient. The de-airingchannel 15 can be used for purging all the air from the valvularstructure 12 prior to insertion of the inflow conduit 10 into the heartthus preventing air from entering the circulatory system. In onevariation, suction can be applied to and/or a fluid such as salineand/or blood can be delivered through the de-airing channel 15 to removeair from the system before the system is completely assembled. Thede-airing channel 15 can place the environment radially external to thesurface of the housing 18 in fluid communication with the attachmentring channel 14.

FIGS. 3 a and 3 b illustrate an attachment ring 22. The attachment ring22 can be attached to the epicardial wall, for example, by suturesthrough the cuffs 19 and 21 and the epicardial wall. After being suturedto the heart, the cuffs 19 and 21 can provide at least mechanicalsupport on the heart wall for the attachment ring 22, which serves as ananchoring point for securing of the inflow conduit 10 after it has beeninserted into the heart for fluid (e.g., blood) communication. Theattachment ring 22 can have an attachment ring wall 29 that defines anattachment ring channel 14. The attachment ring channel 14 can be openat both ends. The inflow conduit 10 can be passed through the attachmentring channel 14, accessing the chamber inside the ventricle. Theattachment ring 22 can have a substantial or nominal height. Theattachment ring wall 29 can be made from a silicone molded body withABS, Delrin, or combinations thereof. The attachment ring 22 can havepolypropylene ring inserts (e.g., to provide circular structure tofacilitate tool and inflow conduit 10 insertion) and reinforcedpolyester mesh (e.g., to prevent tearing). The attachment ring wall 29can be sutured to the cuff 19 and/or 21. The cuff pad 20 can be madefrom PTFE felt.titanium, silicone, or combinations thereof. Theattachment ring 22 can be from about 5 mm to about 25 mm tall. Theattachment ring wall 29 can have a thickness from about 1 to about 3 mm(e.g., not including flanges). The diameter of the attachment ringchannel 14 can range from about 10 mm to about 25 mm.

The attachment ring wall 29 can have a distal band 31 extending radiallyfrom the attachment ring wall 29 at or near the distal terminus of theattachment ring wall 29. The distal band 31 can be integral with theattachment ring wall 29. The distal band 31 can attach to the distaland/or proximal cuff 21. The attachment ring wall 29 can have a proximalband 26 at or near the proximal terminus of the attachment ring wall 29to maintaining a substantially circular cross-section adjacent to wherethe inflow conduit 10 is inserted into the attachment ring channel 14.The proximal band 26 can be a rigid metal or plastic. The proximal band26 can structurally reinforce the proximal end of the attachment ringwall 29. The attachment ring wall 29 can be flexible or rigid. Theseproximal and distal bands 26 and 31 can be used as anchors, attachmentpoints, visual alignment indicators and/or locks to other structures,components, or tools used in the implantation process.

The attachment ring 22 can be attached to the heart by stitching,suturing, or stapling one or more regions on the cuff 19 and/or 21 ofthe attachment ring 22 to the heart. The attachment ring wall 29 isattached to the cuff 19 and/or 21 having an annular shape with a distalcuff 19 or sewing region and a proximal cuff 21 or sewing region. Forexample, the cuffs 19 and/or 21 can be attached to the attachment ring22 by sutures, thread, staples, brads, welding, adhesive, epoxy, orcombinations thereof. The cuffs 19 and 21 extend radially from theattachment ring wall 29 outward. The distal cuff 19 can extend radiallymore outward than the proximal cuff 21, for example, the proximal cuff21 can structurally support the distal cuff 19 and provide a thickerlayer through which sutures can be stitched. The distal cuff 19 and theproximal cuffs 21 can form the shape of cylindrical discs with hollowcenters (i.e., where the attachment ring wall 29 and attachment ringchannel 14 are located). The distal cuff 19 can be on the distal side ofthe distal band 31, and the proximal cuff 21 can be on the proximal sideof the distal band 31 and attached to the distal band 31 and/or theattachment ring wall 29. The distal and proximal cuffs 21 can bestacked. The distal cuff 19 can be attached to the proximal cuff 21, forexample, at the radially outer circumference of the proximal cuff 21.

The cuffs 19 and/or 21 can each have a cuff pad 20 through which thesutures can be passed. The cuff pads 20 can be made from a mesh orfabric material that can be configured to allow penetration by a typicalsurgical needle and suture. The material of the cuff pad 20 can bestrong enough such that the cuff 19 and/or 21 can be secured by suturesagainst the epicardial wall without easily tearing should a small forcebe exerted on the attachment ring 22 by accidentally tugging theattachment ring 22 away from the epicardial wall. The cuff pads 20 canbe flexible. The cuff pads 20 can be configured to affix to suturespassed through the cuff pads 20.

The cuffs 19 and/or 21 can have cuff frames 23 that maintain the planarshape of the cuffs. The cuff frames 23 can also prevent the suture fromtearing through the cuff pad 20 and radially exiting and detaching fromthe cuff. The cuff frames 23 can be rigid circular bands attached to theexternal circumference of the cuff pads 20. The cuff frames 23 can bemetal and/or hard plastic. The suture can be passed through the cuff pad20 radially inside of the cuff frame 23.

The attachment ring wall 29 can have a ring wall interface lip 25 thatcan prevent the clamp 24 from shifting, slipping, or otherwise comingoff the attachment ring wall 29. The ring wall interface lip 25 canextend radially from the attachment ring wall 29 proximal from the cuffs19 and 21.

An integral or separately attached clamp 24 can be on the attachmentring wall 29 distal to ring wall interface lip 25 and proximal to thecuffs 19 and/or 21. The clamp 24 can apply an inward radial forceagainst the attachment ring wall 29. The clamp 24 can exert acompressive radially force around the attachment ring wall 29, forexample, to pressure-fit the inner surface of the attachment ring wall29 to the outer surface of an inflow conduit 10 when the inflow conduit10 is passed through the attachment ring channel 14. The compressiveforce from the clamp 24 can hold and seal the attachment ring 22 againstthe inflow conduit 10. The attachment ring seal 34 can prevent bloodflow from the heart from exiting between the attachment ring 22 and theinflow conduit 10. The inflow conduit 10 can separately seal around thecored hole in the epicardium. The clamp 24 can be on the radial outsideof the attachment ring wall 29 between the ring wall interface lip 25and the cuffs.

FIGS. 4 a and 4 b illustrate that the attachment ring 22 can have anattachment ring seal 34 at the proximal end of the attachment ring wall29. The attachment ring seal 34 can extend radially inward from theattachment ring wall 29 into the attachment ring channel 14. Theattachment ring seal 34 can be flexible. The attachment ring seal 34(and any other seals disclosed herein) can be made from a soft,resilient elastomer or other polymer. The attachment ring seal 34 can beintegral with or separate and attached to the attachment ring wall 29.The attachment ring seal 34 can produce a fluid-tight seal againstelements placed in the attachment ring channel 14, when the element inthe attachment ring channel 14 has an outer diameter larger than theinner diameter of the attachment ring seal 34.

The proximal band 26 can be inside of the ring wall interface lip 25.The ring wall interface lip 25 can extend radially outward from theattachment ring wall 29. The ring wall interface lip 25 can interferencefit against the clamp 24 to prevent the clamp 24 from translatingproximally off the attachment ring wall 29. The ring wall interface lip25 can be attached to and/or abutted against by an element adjacent tothe attachment ring 22. For example, the inflow conduit 10 can abutagainst the ring wall interface to prevent the inflow conduit 10 frompassing too far through the attachment ring channel 14. Also forexample, the valvular structure 12 can attach to the ring wall interfacelip 25. The proximal band 26 also provides structural support and ahemostatic seal when the attachment ring wall interface lip 25 andvalvular structure housing 18 are joined together.

The attachment ring 22 can have one cuff 35. The attachment ring wall 29can have a first distal band 32 on a distal side of the cuff 35 and asecond distal band 33 on a proximal side of the cuff 35. The cuff 35 canbe attached to, or pressure fit between, the first distal band 32 andthe second distal band 33.

FIG. 5 illustrates that the clamp 24 can be made of a single, continuouswire of material. The clamp 24 can be made from a metal and/or polymer(e.g., plastic). The clamp 24 can have a clamp frame 37 to transmit theradially compressive force and clamp handles 36 that can be used to openand/or close the clamp frame 37. The clamp frame 37 can be resilientlydeformable. The clamp frame 37 can have a clamp diameter 38. When theclamp 24 is in a substantially or completely relaxed or unbiasedconfiguration, the clamp diameter 38 can be smaller than the outerdiameter of the attachment ring wall 29 to which the clamp 24 attaches.

The clamp handles 36 can extend radially from the remainder of the clampframe 37. Compressive, squeezing force can be applied to the oppositeclamp handles 36 to move the clamp handles 36 toward each other. Thecompressive force applied to the clamp handles 36 can expand the clampdiameter 38, placing the clamp 24 in an open configuration.

When the clamp 24 is in an open configuration, the clamp 24 can beloaded onto and/or removed from the attachment ring 22. In the openconfiguration, an inflow conduit 10 can be passed through or retractedfrom the attachment ring channel 14.

FIGS. 6 a and 6 b illustrate another variation of the clamp 24. FIG. 6 aillustrates the clamp 24 in an open configuration. The clamp 24 can havea frame made from a band of ribbon with a clamp handle 36 to loosen ortighten the clamp 24. The configuration as shown illustrates that afirst end of the clamp lever 39 is rotatably attached to a firstterminus of the clamp frame 37 and with the second end of the clamplever 39 rotatably attached to the clamp handle 36. The clamp handle 36can be rotatably attached to the second terminus of the clamp frame 37that is not attached to the clamp lever 39. The clamp handle 36 can beattached to the clamp frame 37 at a clamp hinge 40.

FIG. 6 b illustrates the clamp 24 in a closed configuration. In thisillustration, the clamp handle 36 is rotated to cause the clamp frame 37to tighten the clamp frame 37 in the closed configuration. The clamphandle 36 can lie flush against the outer circumference of a length ofthe clamp frame 37. The clamp lever 39 can position a first terminus ofthe clamp frame 37 toward the second terminus of the clamp frame 37 whenthe clamp handle 36 is closed.

The clamp diameter 38 can be smaller when the handle is closed than whenthe handle is open. When the handle is closed, the clamp diameter 38 canbe smaller than the outer diameter of the attachment ring wall 29 towhich the clamp 24 attaches. When the handle is open (as shown in FIG. 6a), the clamp diameter 38 can be larger than the outer diameter of theattachment ring wall 29 to which the clamp 24 attaches. When the handleis open, the clamp diameter 38 can be larger than the outer diameter ofthe ring wall interface lip 25.

FIG. 7 a illustrates that the clamp 24 can be on the attachment ring 22in an open configuration over the attachment ring external wall 29. Withthe clamp 24 in an open configuration, elements such as a coring knife,inflow conduit 10 or other surgical tools, can pass through theattachment ring channel 14. The clamp 24 can be against the outersurface of the attachment ring wall 29 between the ring wall interfacelip 25 and the cuff 35.

FIG. 7 b illustrates that the clamp 24 can be in a closed configurationover the attachment ring external wall 29. With the clamp 24 in a closedconfiguration, the attachment ring wall 29 can compress onto and sealagainst elements placed in the attachment ring channel 14, such as theinflow conduit 10. The clamp 24 can be between the second distal band 33and the ring wall interface lip 25. The clamp 24 can exert a radiallyinward force against the attachment ring wall 29. The closed clamp 24can reduce the diameter of the attachment ring wall 29 and the diameterof the attachment ring channel 14.

FIGS. 8 a through 8 c illustrate that the inflow conduit 10 can beinserted into the attachment ring 22 to access the heart with the inflowconduit 10 and route blood through an inflow conduit channel 178 fromthe heart to the pump 8. The inflow conduit 10 can have an inflowconduit stop 42 configured to abut against or attach to other elements,for example, to preventing the inflow conduit 10 from over-insertionthrough the attachment ring 22. The inflow conduit 10 distal to theinflow conduit stop 42 can have an outer diameter smaller than the innerdiameter of the attachment ring channel 14. The inflow conduit stop 42can have an outer diameter larger than the inner diameter of theattachment ring channel 14.

The clamp 24 can be biased open (e.g., by compressing the clamp handles36 toward each other) when the inflow conduit 10 is inserted into theattachment ring channel 14, for example, to allow the inflow conduit 10to pass freely through the attachment ring channel 14. The clamp 24 canbe released and returned to a compressive state around the attachmentring wall 29 when the inflow conduit 10 is in a desired location withinthe attachment ring 22, for example, to clamp 24 the attachment ring 22onto the inflow conduit 10 and hold the inflow conduit 10 in place.

FIGS. 9 a through 9 c illustrate that the variation of the clamp 24 ofFIGS. 6 a and 6 b can be in an open configuration when the inflowconduit 10 is inserted into the attachment ring channel 14, allowing theinflow conduit 10 to be inserted freely through the attachment ring 22.The clamp handle 36 can be rotated open.

The inflow conduit 10 can be advanced through the attachment ringchannel 14 until the inflow conduit stop 42 abuts the proximal end ofthe attachment ring wall 29, for example at the ring wall interface lip25. The inflow conduit 10 can extend out of the distal end of theattachment ring 22, for example into and within fluid communication withthe chamber of the heart.

When the inflow conduit 10 is in a desired location within theattachment ring 22, the clamp 24 can be closed or released, for example,compressing the attachment ring wall 29 onto the inflow conduit 10. Theinflow conduit 10 can then pressure fit against the inner surface of theattachment ring wall 29, for example holding the inflow conduit 10 inplace relative to the attachment ring 22.

FIGS. 10 a through 10 e illustrate a variation of the valvular structure12 that can have a clamshell housing 18. The valvular structure 12 canhave a housing 18 with a housing first portion 46 separatably attachedto a housing second portion 54. The housing first portion 46 can have arotatable clamshell attachment to the housing second portion 54 and canbe rotated open and removed from the remainder of the ventricular assistsystem. In a closed configuration, the housing portions 46 and 54 candefine a housing channel 58 longitudinally through the housing 18 andopen on each end. The housing first portion 46 can attach to the housingsecond portion 54 at a housing first seam 51 and a housing second seam48. The housing first seam 51 can have a housing first joint 50. Thehousing second seam 48 can have a housing second joint 49.

The housing joints 49 and 50 can be pinned hinges. For example, thefirst and/or second housing joints 49 and/or 50 can have first and/orsecond joint pins 52 and/or 53, respectively. The housing portions 46and 54 can rotate about the housing joints 49 and 50. The respectivepins 52 and 53 can be removed from the housing joints 49 and 50 and thehousing portions 46 and 54 can be separated from each other at thehousing joint 49 and 50. After separation, the housing portions 46 and54 can be reassembled at the housing joints 49 and 50 and the joint pins52 and 53 can be reinserted into the housing joints 49 and 50. When thehousing 18 is separated at one or both joints 49 and 50, the valve 16,which is a discrete and separate element from the housing 18, can comeout of the housing 18 or otherwise be removed or detached from thehousing 18.

One or both of the housing portions 46 and 54 can have de-airing ports62. The de-airing ports 62 can be the ends of the de-airing channels 15.Air can be suctioned out of the de-airing ports 62 and/or saline orblood can be delivered from inside the housing 18 through the de-airingports 62 to remove the air from the volume between the valve 16 and theheart wall during the de-airing process.

The valve 16 can have first, second, third, and fourth valve leaflets56. The leaflets 56 can be flexible and resilient. The leaflets 56 canbe made from an elastomer. The valve 16 can have inter-leaflet seams 64between adjacent leaflets 56. Each leaflet 56 can have an intra-leafletfold 66. Each leaflet 56 can have a leaflet rib 57 or reinforcement onthe inter-leaflet seam 64 or intra-leaflet fold 66, for example toreinforce the leaflet 56 at the seam 64 or fold 66. The leaflets 56 canallow fluids and solids to move in the distal direction through thehousing channel 58. The leaflets 56 can oppose fluids and solids movingin the proximal direction through the housing channel 58. The leaflets56 can close against pressure from the distal side of the leaflets 56,for example, preventing the flow of blood from the heart out of thevalvular structure 12.

The valve 16 can have a valve seal 60 proximal to the leaflets 56. Thevalve seal 60 can extend radially into the housing channel 58. The valveseal 60 can be resilient. The valve seal 60 can seal against an element,such as the coring knife or inflow conduit 10, located in the housingchannel 58. When the leaflets 56 are spread open, the valve seal 60between the seal and the coring knife or inflow conduit 10 can preventthe flow of blood from the heart past the valve seal 60 and out of thevalvular structure 12.

The housing 18 can have a housing seal 47 distal to the valve 16. Thehousing seal 47 can seat in, and attach to the housing 18, via acircumferential housing seal groove 55 in the housing 18. The housingseal 47 can extend radially into the housing channel 58. The housingseal 47 can be resilient. Similar to the valve seal 60, the housing seal47 can seal against an element, such as the coring knife or inflowconduit 10, located in the housing channel 58. When the leaflets 56 arespread open, the seal between the housing seal 47 and the coring knifeor inflow conduit 10 can prevent the flow of blood from the heart outpast the housing seal 47.

The valve 16 can have a valve shoulder 59 that extends radially from thebase of the valve leaflets 56. The valve shoulder 59 can seat andinterference fit into a valve groove 61 recessed in the inner surface ofthe housing 18. The valve shoulder 59 can hold the valve 16 in the valvegroove 61.

FIGS. 11 a through 11 c illustrate another variation of the valvularstructure 12 that can have a latching closure configuration. The housing18 of this variation of the valvular structure 12 can latch closed, asshown in FIGS. 2 a and 2 b, locking the housing first portion 46 to thehousing second portion 54 in a closed configuration. The housing 18 canalso be opened by unlatching the housing first portion 46 to the housingsecond portion 54.

The housing 18 can have a first joint that can have a first joint latch69. The joint latch can be rotated open (as shown), decoupling thehousing first portion 46 and the housing second portion 54 at thehousing first seam 51. The first joint latch 69 can be rotated closed,laying substantially flush with the outer wall of the housing 18. In aclosed configuration, the first joint latch 69 can be closed onto andattach to a first joint catch 70. The first joint latch 69 can be on thehousing second portion 54, the first joint catch 70 can be on thehousing first portion 46.

When the housing first portion 46 is separated from the housing secondportion 54, the housing 18 can be removed from the valve 16. The valve16 is destructible and can be torn away from the ventricular assiststructure by hand or with a knife and removed from the target site afterthe housing 18 is removed. For example, after the inflow conduit 10 isinserted through the attachment ring 22 and the housing 18 is removed,the valve 16 can be torn away from the inflow conduit 10.

The housing first portion 46 and/or housing second portion 54 can eachhave coupling grooves 71 proximal to the valve 16. The coupling grooves71 can be configured to slidably and lockably interface with radiallyextending locking tabs 181 on other components that can interact withthe housing 18 such as the slitting blade case 158, coring knife, inflowconduit 10, or combinations thereof. The locking tabs 181 and couplegroove can interface to hold, fix, or otherwise releasably couple thecomponent inserted through the housing 18 to the housing 18 and to alignthe component inserted through the housing 18 to the housing 18. Forexample, the locking tabs 181 and coupling groove 71 can cause a slitfrom a slitting blade case 158 to be at the same angular orientation andposition as a coring abutment disc later-inserted through the slit, asshown in FIGS. 40 b and 40 c.

FIGS. 12 a through 15 b illustrate variations of the valve 16 withdifferent configurations. FIGS. 12 a and 12 b illustrate that the valve16 shown in FIGS. 10 a through 10 e can be a four-leaflet valve 16. Theinter-leaflet seams 64 can extend radially from the center of the valve16 to the valve shoulder 59 with no inter-leaflet seam extending throughthe valve shoulder 59 or through the valve shoulder 59 to the outercircumference of the valve 16, or combinations thereof. For example, asshown in FIG. 12 c, one of the inter-leaflet seams 64 can extend throughthe valve shoulder 59 while the remainder of the inter-leaflet seams 64can extend to the valve shoulder 59 without extending through the valveshoulder 59, and the one inter-leaflet seam 64 that extends through thevalve shoulder 59 can be aligned with one of the housing seams 51 or 48when loaded in the housing 18.

The inter-leaflet seams 64 can be completely separated seams,perforations, or combinations thereof along the length of the seam(e.g., complete separation between the leaflets 56 and perforation asthe seam extends through the valve shoulder 59). The valve 16 can betearable by hand, for example along the inter-leaflet seam 64. Forvalves 16 with a completely separated inter-leaflet seam 64, no tearingis necessary to separate the valve 16 from an element which the valve 16surrounds, such as the inflow conduit 10. As shown in FIG. 12 c, thevalve can be rotated open, as shown by arrows, in a clamshellconfiguration to release the valve 16 from an inner element or componentwhich the valve 16 surrounds.

FIGS. 13 a through 13 c show another variation of the valve 16. Thevalve 16 can be a quadcuspid (i.e., four-leaflet) valve that can haveinter-leaflet seams 64 that can extend through the valve shoulder 59 tothe outer circumference of the valve 16. FIG. 13 c illustrates that thevalve 16 can be rotated open, as shown by arrows, at a firstinterleaflet seam 64 that extends through the valve shoulder 59 betweenthe first leaflet 68 and the second leaflet 65. The oppositeinter-leaflet seam 64 can extend to, but not through the valve shoulder59, acting as a hinge around which the valve halves can rotate. FIG. 13Dillustrates that the remaining inter-leaflet seams 64—other than theinter-leaflet seam 64 that extends through the valve shoulder 59 betweenthe first leaflet 68 and second leaflet 65—can extend to but not throughthe valve shoulder 59. The valve 16 can be further rotated open tospread open each inter-leaflet seam 64, for example when removing thevalve 16 from the coring tool or inflow conduit 10 placed through thevalve 16.

FIGS. 14 a and 14 b illustrate yet another variation of the valve 16that can be a tricuspid valve (i.e., having three leaflets). FIGS. 15 aand 15 b illustrate yet another variation of the valve 16 that can be abicuspid valve (i.e., having two leaflets).

FIGS. 15 c through 15 e illustrate variations of the valve 16 that canhave opposite inter-leaflet seams 64 that extend through the shoulder ona first side of the valve 16, and not through the shoulder on a secondside of the valve 16, opposite to the first side of the valve 16. Theopposite inter-leaflet seams 64 can converge in the middle of the valve16 to form a single slit along a diameter of the valve 16. The valves 16can be miter valves. The leaflets can join together at miters or bevelsat the inter-leaflet seams 64. The leaflets can pucker or duckbill atthe inter-leaflet seams 64.

FIG. 15 c illustrates a quadcuspid valve 16. FIG. 15 d illustrates abicuspid valve 16. FIG. 15 e illustrates a unicuspid valve 16 (i.e.,having one leaflet) that can have a seam that does not extend to thevalve shoulder. A unicuspid valve is a type of diaphragm valve. Adiaphragm valve can have no more than one seam extending to theshoulder. The seam can be similar in length to the diaphragm seam 88shown in FIGS. 21 a and 21 b.

FIG. 15 f illustrates a diaphragm valve 16 that can have a diaphragm 82but no leaflets. The seam in the valve 16 can be a straight slit or port83 that can be closed in a relaxed an unbiased configuration. The slitor port 83 can extend along a diameter of the valve 16, but not extendto the valve shoulder 59. The valve 16 can duckbill, pucker or miteraround the port 83.

FIGS. 16 a and 16 b illustrate a variation of the valvular structure 12that can have a valve 16 that can be an inflatable membrane 73. Thevalve 16 can be inflated and deflated to close and open, respectively,the valve 16. The valve 16 can have an inflatable valvular chamber 75between the inflatable membrane 73 and the housing 18. The inflatablemembrane 73 can be resilient. The inflatable membrane 73 can be in adeflated and open configuration, as shown in FIG. 16 a.

FIG. 16 b illustrates that the inflatable membrane 73 can be in aninflated and closed configuration. The inflatable valvular chamber 75can be pressurized, as shown by arrows, with a liquid (e.g., saline) orgas (e.g., carbon dioxide) to inflate the inflatable membrane 73. Theinflatable membrane 73 can seal around elements in the housing channel58, such as the coring knife or inflow conduit 10. The inflatablemembrane 73 can have a high-friction surface facing the housing channel58 that can pressure-fit against the coring knife or inflow conduit 10,fixing the coring knife or inflow conduit 10 in the housing channel 58.Alternatively, the inflatable membrane 73 can have a low-frictionsurface facing the housing channel 58 that can allow the coring knife ofinflow conduit 10 to slide within the housing channel 58 against theinflated inflatable membrane 73.

The pressure in the inflatable valvular chamber 75 can be released,returning the inflatable membrane 73 to the open configuration andreleasing the pressure-fit against any elements in the housing channel58.

FIG. 17 a illustrates a variation of the valvular structure 12 that canhave a valve 16 that can be a torsioning or twisting membrane 77. Thetop and bottom of the housing 18 can be counter-rotated to open or closethe twisting membrane 77. The twisting membrane 77 can be loose andnon-resilient or taught and resilient and elastic. The housing firstportion 46 and second portion can each have a top rotatably attached toa bottom. The twisting membrane 77 can be attached to housing tops 78(the housing first potion top is shown) and bottoms 79 (the housingfirst potion bottom is shown) by a membrane anchor ring 76. The twistingmembrane 77 can be in an untwisted and open configuration, as shown.

FIG. 17 b illustrates that the housing tops 78 can be rotated withrespect to the housing bottoms 79, as shown by arrows, for example, topartially or completely close the valve 16. The twisting membrane 77 cantwist upon itself and around elements in the housing channel 58. Thetwisting membrane 77 can be in a twisted and closed configuration. Thetops and bottoms can be counter-rotated to untwist and open the twistingmembrane 77.

FIGS. 18 a and 18 b illustrate another variation of the valve 16 thatcan be a diaphragm valve that can be closed in an unbiased configurationand stretched open when the inflow conduit 10 or coring knife is pushedthrough the diaphragm valve. The valve 16 can have a first diaphragm 80and a second diaphragm 86. The diaphragms can be made from resilientmaterial, such as an elastomer, or combinations thereof. For example,the diaphragm can be made from silicone, polyurethane or other bloodcompatible polymers. The first diaphragm 80 can be in contact with andattached to the second diaphragm 86.

The first diaphragm 80 can have a first diaphragm port 81 that canreceive the inflow conduit 10 or coring knife. The second diaphragm 86can have a second diaphragm port 85 that can also receive the inflowconduit 10 or coring knife. The diaphragm ports can be circular. Thediaphragm ports can be resiliently expandable. For example, when a solidelement, such as the inflow conduit 10 or coring knife, with a diameterlarger than the diaphragm ports is forced through the diaphragm portsthe diaphragm ports can expand in shape and size to allow the solidelement to pass through the ports and can seal against the solidelement. When the solid element is removed from the diaphragm ports, thediaphragm ports can return to the relaxed, unbiased, shape and size ofthe diaphragm port.

The first diaphragm 80 can have a diaphragm interface lip 84. Thediaphragm interface lip 84 can be used to hold to diaphragm in the valvegroove 61 in the housing 18. The diaphragm interface lip 84 can be aring around the outer circumference of the first diaphragm 80 that canbe raised or thickened compared to the remainder of the first diaphragm80. The diaphragm interface lip 84 can be formed a result of theattachment of the second diaphragm 86 and the first diaphragm 80. Forexample the diaphragm interface lip 84 can be a rib formed by fusing,gluing or welding, or a reinforcement.

The second diaphragm 86 can have a diameter smaller than the diameter ofthe first diaphragm 80. The second diaphragm 86 can be attached to thefirst diaphragm 80 at or near the outer circumference of the seconddiaphragm 86. The second diaphragm 86 can attach to the first diaphragm80 on the diaphragm interface lip 84 or on the face of the firstdiaphragm 80 on the opposite side of the diaphragm interface lip 84.

When the first diaphragm 80 and the second diaphragm 86 are attached,the first diaphragm port 81 can be incongruous from (i.e., notoverlapping with) the second diaphragm port 85 when the first and seconddiaphragms 80 and 86 are in relaxed, unbiased configurations. When thediaphragm valve 16 is in a relaxed, unbiased configuration, the firstdiaphragm port 81 and the second diaphragm port 85 can overlapcompletely, partially or not at all (as shown). The diaphragm valve 16can have a substantially fluid-tight seal in a relaxed configuration.

The diaphragm valve 16, or other valve variations such as the leafletvalves, can allow a check flow, for example a small amount of blood flowused to test or confirm if positive blood pressure exists on theopposite side of the valve 16. For example, the pressure between thefirst diaphragm 80 and the second diaphragm 86 can be insufficient tocompletely seal when pressurized blood from the heart is in contact withthe diaphragm valve 16, and a small trickle or drip-flow of blood canpass through the diaphragm ports 81 and 85. In an alternative variation,the leaflets can have a check flow channel, a small channellongitudinally aligned in the inter-leaflet seam that can allow checkflow to flow between adjacent leaflets in a direction opposite to thelow-resistance orientation of valve.

FIGS. 19 a and 19 b illustrate a variation of the attachment ring 22with an integrated diaphragm valve 16. The first diaphragm 80 can beintegral with the attachment ring wall 29. The first diaphragm 80 cansubstantially close the end of the of the attachment ring channel 14.The second diaphragm 86 can be attached to the first diaphragm 80 and/orthe attachment ring wall 29. Similarly, the other valve types describedcan also be integrated with the attachment ring 22. For example, FIGS.19 c and 19 d illustrates a variation of the attachment ring 22integrated with a quadcuspid valve 16. FIG. 20 illustrates the explodedassembly of a variation of the diaphragm valve 16 in a valvularstructure 12 attached to an attachment ring 22. The valve 16 can beseparate and detachable from the attachment ring 22. The diaphragm 82can be attached to a diaphragm flap 87. The housing first portion 46 andhousing second portion 54 can have a diaphragm groove 90circumferentially around the radially inner surface of the housing 18.The diaphragm interface lip 84 can seat in and attach to the diaphragmgroove 90.

The housing first portion 46 and housing second portion 54 can have aring groove 94 circumferentially around the radially inner surface ofthe housing 18. The ring wall interface lip 25 can seat in and attach tothe ring groove 94.

The housing first portion 46 can have a housing first handle 93. Thehousing second portion 54 can have a housing second handle 91. Thehousing handles 91 and 93 can be pulled to separate the housing firstportion 46 from the housing second portion 54. For example, the housingfirst seam 51 and the housing second seam 48 can be completely separatedor perforated.

The tape 89 can be a substantially unresilient, flexible polymer striptightly wrapped around the radial outer surface of the housing 18. Thetape 89 can radially compress the housing first portion 46 and thehousing second portion 54, keeping the housing first portion 46 attachedto the housing second portion 54. The tape 89 can have an adhesiveapplied to the radial inner surface. The tape 89 can be wound once ormore around the housing 18 and can stick to the housing 18 and to innerlayers of the tape 89 itself.

Alternatively, the tape 89 can be an elastomeric hollow cylinder orband. The tape 89 can be placed onto the housing 18 by stretching thetape 89 over the housing 18 and releasing the tape 89 from thestretching force, resiliently radially compressing the housing 18.

FIGS. 21 a through 21 c illustrate another variation of the diaphragmvalve 16. FIG. 21 b illustrates that the diaphragm 82 can have adiaphragm seam 88 extending from the diaphragm port 83 to the externalcircumference of the diaphragm 82. The diaphragm seam 88 can be acomplete split separating each side of the diaphragm seam 88, allowingan element, such as the inflow conduit 10 or coring knife, to passthrough the diaphragm 82 at the diaphragm port 83 and/or the diaphragmseam 88. The diaphragm port 83 can be in the radial center of thediaphragm 82. The diaphragm flap 87 can cover the diaphragm port 83.

FIG. 21 c illustrates that the diaphragm flap 87 can attach to thediaphragm 82 at an attachment area 96. The diaphragm flap 87 can beunattached to the diaphragm 82 except for at the attachment area 96,allowing the diaphragm flap 87 to open out of the way when an element ispushed through the diaphragm port 83 and/or diaphragm seam 88. Thediaphragm flap 87 can be rigid or flexible. The diaphragm flap 87 can beresilient. The diaphragm flap 87 can be made from the same materials asthe diaphragm 82.

The diaphragm flap 87 can extend to the external circumference. Thediaphragm flap 87 can cover the diaphragm port 83 and the diaphragm seam88. The diaphragm flap 87 can cover a portion of the side of thediaphragm 82 and leave a portion of the side of the diaphragm 82 exposed(as shown) or can cover the entire side of the diaphragm 82.

When the fluid pressure on the side of the diaphragm 82 of the diaphragmflap 87 exceeds the fluid pressure on the side of the diaphragm 82opposite the diaphragm flap 87, the diaphragm flap 87 can press againstthe diaphragm seam 88 and diaphragm port 83, further sealing thediaphragm 82.

When an element, such as the coring knife or inflow conduit 10, isforced through the diaphragm 82 from the side of the diaphragm 82opposite of the diaphragm flap 87, the element can press open thediaphragm 82 at the diaphragm port 83 and diaphragm seam 88, and thediaphragm flap 87 can be pressed aside as the element moves through thediaphragm 82.

FIG. 22 illustrates that when the valvular structure 12 is assembled thediaphragm interface lip 84 can be seated in the diaphragm groove 90 ofthe housing 18. The housing first portion (not shown) and the housingsecond portion 54 can be compressed together by tape 89 wound around theexternal circumference of the housing 18.

FIG. 23 illustrates that the valvular structure 12 can have a lockingring 98 that can be used to compress the attachment ring 22 against aninflow conduit 10 placed in the attachment ring channel 14. For example,the locking ring 98 can be used in lieu of or in addition to the clamp24. The locking ring 98 can be releasably attached to the radiallyinternal surface of the housing 18. The locking ring 98 can be separablyattached to the housing 18 with circumferential rails and interfacinggrooves on the radially outer surface of the locking ring 98 and theradially inner surface of the housing 18.

The de-airing ports 62 (as shown) can act as handle ports and/or be usedto de-air the valvular structure 12. The handle ports can attach tohousing handles or can be open to be used for de-airing, as describedherein.

FIG. 24 illustrates that the tape 89 can be wound radially around theouter surface of the housing 18. The tape 89 can compress the housingfirst portion 46 to the housing second portion 54. The tape 89 can haveadhesive, for example, on the side of the tape 89 facing the housing 18.The tape 89 can have no adhesive and be elastic, for example, attachingto the outer surface of the housing 18 by a friction-fit from the tape89 elastically compressing against the housing 18.

FIG. 25 illustrates that the valvular structure 12 can be attached tothe attachment ring 22, for example, by snapping the valvular structure12 onto the attachment ring 22. The valvular structure 12 can beattached to the attachment ring 22 before or during the VAD implantprocedure.

The valvular structure 12 can be translated, as shown by arrow, over theattachment ring wall 29. The ring wall interface lip 25 can have asloped side facing in the direction of the on-loading valvular structure12. As the valvular structure 12 is being pressed onto the attachmentring 22, the portion of the housing 18 that is distal to the ring groove94 can deform over the sloped side of the ring wall interface lip 25.The ring wall interface lip 25 can then seat and interference fit intothe ring groove 94.

FIGS. 26 a and 26 b illustrate another variation of snapping thevalvular structure 12 onto the attachment ring 22. In this variation,the valvular structure 12 can have a locking ring 98. The locking ring98 can have a locking ring wall angle 100 with respect to the housingchannel longitudinal axis 103. The locking ring wall angle 100 can be,for example, from about 3° to about 15°, for example about 10°.

The ring wall interface lip 25 can have a sloped side facing in thedirection of the on-loading valvular structure 12. The sloped side ofthe ring wall interface lip 25 can form a ring wall angle 102 with theattachment ring channel longitudinal axis 101. The ring wall angle 102can be from about 3° to about 15°, for example about 10°. The ring wallangle 102 can be substantially equal to the locking ring wall angle 100.

The valvular structure 12 can be pressed onto the attachment ring 22,over the attachment ring wall 29, as shown by arrow. As the valvularstructure 12 is being pressed onto the attachment ring 22, the portionof the housing 18 distal to the ring groove 94 can deform over thesloped side of the ring wall interface lip 25.

FIG. 26 b illustrates that the valvular structure 12 can be pressed ontothe assembly ring, as shown. The ring wall interface lip 25 can seat andinterference fit into the ring groove 94.

Method of Using

FIGS. 27 a and 27 b illustrate a process for surgically implanting aventricular assist system. It should be appreciated to a person withordinary skills in the art that the surgical, preparation, andimplantation processes described can be performed in a different orderas presented. The surgical process for implanting the ventricular assistsystem can begin by anesthetizing the patient and placing the patient ina supine position. The left ventricular apex and ascending aorta 104 canthen be exposed using a less invasive approach, such as a left subcostalincision and a second right anterior mini-thoracotomy, or a commonsternotomy which is typically more invasive but allows more space for asurgeon to operate.

The method can include space for placement of an outflow conduit 2/graftby tunneling from a subcostal position to an aortic location. Forexample, an outflow graft tunnel can be created between the twoincisions (e.g., the left subcostal incision and the right anteriormini-thoracotomy) with a malleable tunneler and/or a curved tunneler.The tunneler 177 can begin at the left subcostal thoracotomy and tunnelto the right anterior mini-thoracotomy.

The tunneler 177 can have a tunneler tip that can then be removed fromthe tunneler once the tunneler has reached the right anteriormini-thoracotomy. The outflow graft connector can then be attached tothe end of the tunneler and pulled back through the tunnel createdbetween the incisions. The outflow graft can then be connected to a pumpsizer at the target site for the pump 8. The pump sizer is a plasticelement the size and shape or the pump 8 that can be used to check thefit of the finally deployed pump 8 by inserting the pump sizer at thetarget site before inserting the pump 8.

With the outflow graft attached to the pump sizer, the outflow graft canbe measured and cut to length to fit the space between the pump 8 andthe aorta 104 with enough slack in the outflow conduit 2 to allowmovement of the pump 8 and organs, but not too much slack to enablekinking of the outflow conduit 2.

If the process does not include the use of a heart-lung by-pass machineand is performed while the heart 106 is pumping, the outflow graft canthen be anastomosed to the aorta 104 using a side biting clamp to holdthe aorta 104 and an aortic punch 126 to make the incision in the aorta104.

After blood is allowed to flow into the outflow graft for purging airfrom inside the outflow graft or conduit 2, a clamp 131, such as ahemostat, can then be placed on the outflow graft 2, or a balloon 135can be inflated in the outflow graft to stanch the flow of blood fromthe aorta 104 through the outflow graft 2. The control of blood from theheart 106 and de-airing can also or additionally be performed bycreating a slit into the wall of the outflow graft 2. A balloon catheter132 can then be delivered into the outflow graft 2 through the slit. Theballoon 135 can then be positioned in the pump outflow connector andinflated to plug the pump outflow connector. End and or side ports onthe balloon catheter 132 can be used for de-airing.

The pump 8 and the inflow conduit 10 or inflow graft can be preparedprior to connection of the inflow conduit 10 to the heart 106. Theproximal end of the inflow conduit 10 is connected to the pump 8 in asaline bath to purge all air from the inflow conduit 10 and the pump 8prior to having the distal end of the inflow conduit 10 connected to theheart 106. In this preparation process, the entire inflow conduit 10 andthe pump 8 can both be submerged into a saline bath and connected. Ablockage at the outflow end of the pump 8 is placed to prevent bloodfrom escaping after the distal end of the inflow conduit 10 is connectedto the heart 106.

Prior to connection of the inflow conduit 10 to the heart 106, theattachment ring 22 can be sewed onto the epicardial surface of thetarget connection area on the heart 106. In one variation, sutures canbe used to secure the cuff 35 of the attachment ring 22 onto the heart106. The valvular structure 12 or external seal can then be securedagainst the attachment ring 22, for example, by placing and securing thevalvular structure 12 over the walls forming the attachment ring channel14. A slitting blade or tool can be inserted through the valvularstructure 12 and the attachment ring 22 to create a slit into themyocardium at the target connection area. A coring knife 140 can then beinserted through the slit and used to core a portion of the myocardium.The inflow conduit 10 can then be inserted through the valvularstructure 12 and the attachment ring 22 to into the opening of the heart106 created by the coring knife. The inflow conduit 10 can be secured tothe attachment ring 22 with the radial clamp 24. The valvular structure12 including the external seal can then be removed. The inflow conduit10 can be inserted further into the left ventricle. The radial clamp 24can then be radially compressed (e.g., released from a radially expandedconfiguration) and/or locked to secure the inflow conduit 10 to theattachment ring 22.

The entire system can be completely de-aired in the process ofconnecting the outflow graft to the pump 8. De-airing or the removal ofall the air from the outflow graft and the pump 8 can be performed withthe use of a de-airing bladder, enclosure or a bath of saline. Theunconnected end of the outflow graft can be submerged into the bath ofsaline along with the outflow end of the pump 8 that has the blockage.The clamp or balloon 135 can be removed from the outflow graft and allthe air in the outflow graft and pump 8 can be allowed to escape orpushed by the flow of blood from the aorta 104 into the bladder,enclosure, or the bath of saline, for de-airing. Similarly, the outflowend of the pump 8 with the blockage is also submerged into the salinebath. Once the hemostatic outflow graft clamp 131 is removed from theoutflow graft and the blockage is removed from the outflow end of thepump 8, any air remaining in either the outflow graft or in the pump 8will be allowed to escape into the saline bath or enclosure. If theballoon 135 had previously been inserted into the pump outflowconnector, the de-airing can occur by releasing the hemostatic clamp 131from the outflow graft 2 resulting in blood from the aorta 104 floodingand bleeding out the outflow graft 2. The outflow graft 2 can then beconnected to the pump outflow connector. The balloon 135 can be deflatedand the balloon catheter 132 can then be pulled out from outflow graft2. The hole in the site of the outflow graft 2 used for introducing theballoon catheter 132 can then be closed with a purse string suture. Theoutflow graft 2 is connected to the outflow end of the pump 8 after airis removed from the system.

A tunnel can be formed for the percutaneous lead 5 to extend from thepump 8 out of the body. The pump 8 can then be turned on to run andassist the blood flow from the left ventricle. The surgical wounds onthe patient can then be closed.

FIGS. 28 to 35 will collectively illustrate the process of accessing theheart 106 and target implantation vasculature and the tools used tocreate a tunnel for an outflow conduit 2. FIGS. 28, 32 and 35 illustratethe process of creating a tunnel and implanting an outflow conduit 2 inthe tunnel, and FIGS. 29 a through 31 illustrate the variations of toolsused for this tunnel creation process. FIGS. 33 a through 33 cillustrate the process and tools for creating an aortotomy 128 in thetarget vasculature for an anastomotic connection with the outflowconduit 2. FIGS. 34 a through 34 b illustrate the processes and toolsfor preventing blood from spilling out of the outflow conduit 2 after itis connected to the target vasculature.

FIG. 28 a illustrates the creation of a tunnel for the outflow conduit 2without a sternotomy. FIG. 28 b illustrates that when a sternotomy isperformed, creating a sternotomy opening 107, there is no need totunnel.

In a less invasive variation of the procedure, as shown in FIG. 28 a,the target site can be accessed by making a first incision 110 caudallyor inferior to the target site, for example just below the apex on theleft side of the heart 106. A second incision 108 can be made cranial tothe target site, on an opposite side of the target site from the firstincision 110. The second incision 108 can be made near the right secondintercostal to provide access to the aorta 104. The tunneler 177 canthen be inserted, as shown by arrow 111, into the first incision 110 andtunneled between the first and second incision 110 and 108, as shown byarrow 109. The end of the tunneler 177 can then exit, as shown by arrow105, from the patient at the second incision 108, or be inside thepatient but accessible from the second incision 108.

FIGS. 29 a to 30 b illustrate variations of a tunneler 177 that can beused for creating the outflow conduit tunnel FIG. 29 a illustrates oneexample of a tunneler 177 that can have an elongated tunneler shaft 115.The tunneler 177 can have a tunneler handle 114 at a proximal end of thetunneler shaft 115. The tunneler shaft 115 can be straight when in atorsionally unstressed state. The tunneler shaft 115 is of asubstantially smaller diameter than the distal attachment cone 118 sothat it can be malleable or flexible for shaping into a configurationthat fits the anatomy of the patient. The tunneler 177 can have a distalattachment cone 118 at the distal end of the tunneler shaft 115. In onevariation, this distal attachment can be a bullet tip 124 at the distalend of the tunneler 177. The bullet tip 124 can have a smooth or flushseam with the distal attachment cone 118. The bullet tip 124 can beremoved from the distal attachment cone 118 and expose or be replacedwith different distal attachment interface configurations. For example,the bullet tip 124 can be attached to, or replaced with, a distalattachment collet 123 extending distally from the distal attachment cone118, as shown in FIG. 29 b. Similarly, the bullet tip 124 can beattached to, or replaced with, a distal attachment bolt 122 extendingdistally from the distal attachment cone 118, as shown in FIG. 29 c. Thedistal attachment bolt 122 can have helical thread 121. The objective ofthe distal attachment bolt 122 and the distal attachment collet 123 arefor attachment with a proximal end of the outflow graft as will beillustrated further below.

FIGS. 30 a and 30 b illustrate another variation of the tunneler 177that can have an outer sheath 125 attached to the distal attachment cone118. The tunneler shaft 115 can be separate from the outer sheath 125and distal attachment cone 118. The outer sheath 125 can be of adiameter that is similar to the diameter of the distal attachment cone118 and can be hollow. While the diameter of the tunneler shaft 115 andthe outer sheath 125 differs, the outer sheath 125 and the tunnelershaft 115 can have substantially equal radii of curvature. The tunnelershaft 115 and outer sheath 125 can be rigid. The tunneler shaft 115 canbe slidably received by the outer sheath 125.

The tunneler 177 can be inserted through the first incision 110 at adesired location in the abdomen and/or thorax to create the tunnel forultimate placement of the outflow conduit 2. The bullet tip 124 can beconfigured with a blunt tip to atraumatically separate or create a paththrough tissue when the tunneler 177 is being inserted through thepatient.

FIG. 31 illustrates that the bullet tip 124 can be removed and theoutflow conduit coupler 4 can be attached to the distal attachmentinterface. The outflow conduit 2 can extend from the terminus of thetunneler 177. The tunneler 177 can be used to manipulate the locationand orientation (i.e., rotate, twist, translate, steer) of the outflowconduit 2.

The outflow conduit 2 can be attached to the tunneler 177 after thedistal end of the tunneler 177 is passed through the patient and out of,or adjacent to, the second incision site, such as a surgical openingnear the aorta 104 like a right anterior mini thoracotomy or a ministernotomy near the aorta 104. FIG. 32 illustrates that when the distalattachment interface is positioned at the distal end of the tunnel orout of the second incision 108, the bullet tip 124 can be removed fromthe distal attachment interface and the outflow conduit coupler 4 can beattached to the distal attachment interface. The tunneler handle 114 canthen be pulled to draw the outflow conduit coupler 4 and outflow conduit2 through the tunnel.

FIG. 33 a illustrates the use of an aortic clamp 127 to clamp a portionof the wall of the aorta 104. This aortic clamp 127 can be a side-bitingclamp of any shape, and is typically used when the vasculature (e.g.,aorta 104) is still filled with blood, for example, when a heart-lungby-pass machine is not used. An aortic punch 126, or scalpel or othertool can be applied to the clamped portion of the aorta 104 to create asmall opening in the vasculature or target vessel (e.g., aorta 104), asshown in FIG. 33 b. FIG. 33 c illustrates that the outflow conduit 2 canthen be attached to the target vessel by attaching the circumferentialedge of the distal end of the outflow graft/conduit around the openingwith sutures (as shown), staples, clips, brads, glue, or combinationsthereof.

FIG. 34 a illustrates removal of the aortic clamp 127 from the aorta104. Once the aortic clamp 127 is removed, blood flow 130 through theaorta 104 will branch off and flow through the outflow conduit 2, asshown by arrows. If the outflow conduit 2 is not obstructed, the bloodflow 130 from the aorta 104 can flow through the outflow conduit 2 andexit through the (proximal) open end of the outflow conduit 2.

FIG. 34 b illustrates a variation of a method for stanching the bloodflow 130 through the outflow conduit 2. A vascular clamp 131 can beplaced on the outflow conduit 2 to compress the outflow conduit 2,closing and obstructing the outflow conduit 2 and stanching the flow ofblood from the aorta 104 through the outflow conduit 2.

FIG. 34 c illustrates another variation of a method for stanching bloodflow 130 through the outflow conduit 2. An inflatable balloon 135,similar to an angioplasty balloon, can be inserted through the wall ofthe outflow conduit 2. The balloon 135 can be in fluid communicationwith a catheter 132. The balloon 135 can be inflated with a gas (e.g.,carbon dioxide) or liquid (e.g., saline.) The balloon 135 can beinflated when in the outflow conduit 2, closing the outflow conduit 2and stanching the flow of blood from the aorta 104 through the outflowconduit 2. The balloon 135 can be made of a single material along theentire surface of the balloon 135.

FIG. 34 d illustrates yet another variation of a method for stanchingblood flow 130 through the outflow conduit 2. The balloon 135 can becovered with two or more materials. In a first variation, the balloon135 can be a composite balloon made of two sub-balloons, the firstsub-balloon covered with a first material and having a first volume, andthe second sub-balloon covered with the second material and having asecond volume. In a second variation, the balloon 135 cave have a firstvolume covered by the first material and separated by a balloon septum185 from the second volume covered in the second material. The firstvolume can be in fluid communication with a first channel in thecatheter 132, and the second volume can be in fluid communication with asecond channel in the catheter 132 or a second catheter. The firstmaterial can be on the balloon distal surface 133 and the secondmaterial can be on the balloon proximal surface 134. The first materialon the balloon distal surface 133 can be gas impermeable. The secondmaterial on the balloon proximal surface 134 can be made from a materialthat can be gas permeable, but not liquid permeable (i.e., a breathablemembrane such as PTFE or acrylic copolymer). The balloon distal surface133 can face the aorta 104 and the balloon proximal surface 134 can faceaway from the aorta 104 when the balloon 135 is inserted in the outflowconduit 2 and inflated.

When de-airing the outflow conduit 2, fluid (e.g., blood and residualair) can be pumped from the pump 8 through the outflow conduit coupler4. Air in the VAD can pass through the balloon proximal surface 134 andinto the balloon 135. The balloon distal surface 133 and first volumecan be inflated to obstruct the air from flowing through the vessel andforce the air into the balloon proximal surface 134 while allowing theblood and/or saline to flow through the outflow conduit 2 and into theaorta 104. The air captured in the balloon 135 can be withdrawn throughthe catheter 132.

FIG. 35 illustrates that the outflow conduit 2 can be drawn through thetunnel, for example, positioning the outflow conduit coupler 4 near thefirst incision 110 or otherwise at or adjacent to the target site forthe pump 8. As described above, the outflow conduit 2 can be connectedto the aorta 104 (i.e., aortic anastomosis) with an aortic attachmentdevice, such as aortic sutures 117. The aortic anastomosis can occurbefore or after the outflow conduit 2 is drawn into and/or through thethorax, for example, by the tunneler 177.

After the outflow conduit 2 is drawn through the thorax, the attachmentring 22 can be sutured to the heart apex 119 with an apical attachmentdevice, such as apical sutures 113. The attachment ring 22 can be placedagainst, and attached to, either the left (e.g., at the apex) or rightventricles or the left or right atria. The apical sutures 113 can be thesame or different suture material and size as the aortic sutures 117.The attachment ring 22 can be attached to the apex with or without thevalvular structure 12 attached to the attachment ring 22.

FIGS. 36 a through 38 illustrate variations of a cutting tool, such asthe coring knife 140, that can be used to core a piece of the epicardialtissue while the heart 106 is beating. FIGS. 36 a through 36 eillustrate a variation of the coring knife 140 with a cylindrical coringblade 137 configured to chop or shear heart tissue against an abutmentsurface on the proximal side of a conical knife head 136. FIGS. 37 athrough 37 d illustrate another variation of the coring knife 140 thatcan have a rotatable coring abutment 145 to insert through a small slitin the heart 106 and then rotate to squeeze against and compress theheart tissue which is desired to be cored. FIG. 38 illustrates a yetanother variation of the coring knife 140 that has a foreblade 152 thatis independently deployable from the knife head 136.

FIGS. 36 a through 36 d illustrate a variation of the coring knife 140.The coring knife 140 can have a hollow cylindrical coring blade 137. Thecoring knife 140 can have a conical or bullet-shaped knife head 136. Theknife head 136 can be shaped to push apart a pre-cut slit in epicardialtissue to introduce the knife head 136 into the left ventricle. Theproximal surface of the knife head 136 can be a coring abutment 145 thatthe coring blade 137 can cut against.

The coring knife 140 can have a knife handle 139 at the proximal end ofthe coring knife 140. The knife handle 139 can be fixed to a coringcontrol shaft 143. The coring control shaft 143 can be fixed to theknife head 136. Translation of the knife handle 139 can directly controltranslation of the knife head 136. The knife can have a knife stop 138radially extending from the body of the coring knife 140. The knife stop138 can limit the extent of the translation of the knife handle 139, andtherefore the knife head 136, with respect to the coring blade 137. Theknife stop 138 can prevent over insertion of the coring blade 137 intotissue. For example, in use the knife stop 138 can abut the attachmentring 22 or valvular structure housing 18 preventing or minimizing therisk of inserting the coring blade 137 through the heart wall and intothe septum.

FIG. 36 e illustrates that the knife handle 139 can be translateddistally, as shown by arrow, to translate the knife head 136 distally(i.e., extend), as shown by arrow, away from the coring blade 137. Theknife handle 139 can be translated proximally, as shown by arrow, totranslate the knife head 136 proximally (i.e., retract), as shown byarrow, toward the coring blade 137. The coring abutment 145 caninterference fit against the distal cutting edge of the coring blade137. The coring abutment 145 can move within and adjacent to the coringblade 137, for example when the outer diameter of the coring abutment145 is smaller than the inner diameter of the distal end of the coringblade 137. In this configuration, the coring abutment 145 can sheartissue against the coring blade 137.

FIGS. 37 a and 37 b illustrate a variation of the coring knife 140 thatcan have a rotatable coring abutment 145 that can be passed through aslit in the heart wall and then rotated to face the coring blade 137.The coring abutment 145 can be a circular disc. If the slit in the heartwall is not already created when the coring abutment 145 is passedthrough the heart wall and/or the slit is not large enough for thecoring abutment 145 to pass, the circular disc of the coring abutment145 can be used to create the slit in the heart wall. The coringabutment 145 can be rotatably attached to a control arm 146. The controlarm 146 can be attached to the knife handle 139 in a configurationallowing the knife handle 139 to rotate the coring abutment 145 throughmanipulation of the control arm 146. The knife handle 139 can berotatably attached to the proximal end of the coring control shaft 143.

The outside surface of the coring control shaft 143 can have a helicalcoring groove, for example along the length of the coring control shaft143 that passes through the coring knife case 141. The coring knife case141 can have a guide peg 148 that extends radially inward from thecoring knife case 141. The guide peg 148 can be fixed to the coringknife case 141. The guide peg 148 can seat in the helical coring groove,controlling the movement of the coring control shaft 143 with respect tothe coring knife case 141. For example, the coring blade 137 can berotated helically with respect to the coring knife case 141.

FIG. 37 c illustrates that the knife handle 139 can be rotated, as shownby arrow 142, rotating the coring abutment 145, as shown by arrow 149.The plane defined by the coring abutment 145 in a rotated configurationcan be parallel to the plane defined by the cutting edge of the coringblade 137.

FIG. 37 d illustrates that the knife handle 139 can be moved in ahelical motion, as shown by arrow 144, helically moving the coringcontrol shaft 143 and coring blade 137, as shown by arrow 150. Thehelical motion of the knife handle 139 can be constrained by the guidepeg 148 slidably fitting into the helical coring guide 147. The coringblade 137 can be helically rotated and translated to abut the proximalsurface of the coring abutment 145. The coring blade 137 can be rotatedand translated until the coring blade 137 abuts the coring abutment 145.

FIG. 38 illustrates that the coring knife 140 can have a foreblade 152that can be used to create a slit in the epicardial tissue through whichthe coring knife 140 can be inserted into the ventricle. The coringknife 140 with a rotatable coring abutment 145 can also be configuredwith an integral foreblade 152. The foreblade 152 can be controllablyextended distally out of the distal surface of the knife head 136. Thecoring knife 140 can have a foreblade control knob 155 that can be usedto extend and retract the foreblade 152. The foreblade control knob 155can be fixed to the foreblade 152 by a foreblade control shaft 174,shown in FIGS. 41 b through 41 d. The foreblade control knob 155 can betranslated proximally and distally, as shown by arrows 154, within aknob port 157 to translate the foreblade 152 proximally and distally,respectively, as shown by arrows 153, with respect to the knife head136.

Translating the knife handle 139, as shown by arrows 162, can translatethe knife head 136, as shown by arrows 151, independently of theforeblade 152. Translating the knife handle 139 can extend and retractthe coring blade 137. The foreblade control knob 155 can be rotated,shown by arrows 156, to lock or unlock the translation of the foreblade152 to the translation of the knife handle 139.

The knife head 136 can have a chisel-tipped configuration. The distalend of the knife head 136 can be traumatic or atraumatic.

FIGS. 39 a and 39 b illustrate that the coring knife 140 can beinserted, as shown by arrow, through the housing 18 of the valvularstructure 12 and the attachment ring 22. The leaflets 56 of the valve 16can resiliently deform away from the coring knife 140. The leaflets 56,valve seal 60, housing seal 47, or combinations thereof, can formfluid-tight seals around the coring knife 140, for example to prevent orminimize the flow of blood from the heart 106 and out of the valvularstructure 12 during use of the coring knife 140.

FIGS. 40 a through 40 i illustrate a variation of a method for coringthe heart 106 and attaching the inflow conduit 10 to the heart 106 whilethe heart 106 is beating. FIG. 40 a illustrates that the attachment ring22 can be placed against the wall of the heart 106. One or more sutures113 can be sewn through the cuff 35 and the heart 106, fixing theattachment ring 22 to the heart 106. The clamp 24 can be attached to theattachment ring 22 in an open configuration, as shown. The valvularstructure 12 can be attached to the attachment ring 22 before or afterthe attachment ring 22 is attached to the heart 106. The air can beremoved from the attachment ring channel 14 and/or housing channel 58 atany time by inserting blood and/or saline into the de-airing port 62and/or by applying suction to the de-airing port 62, for example beforeslitting or coring an opening into the heart wall.

FIG. 40 b illustrates that the initial slit in the heart wall can bemade by a slitting blade. The slitting blade can be contained in aslitting blade case 158 and configured to extend from and retract intothe slitting blade case 158. The slitting blade case 158 can be insertedthrough the valvular structure 12 and attachment ring 22. The slittingblade case 158 can have slitting blade handles 160 and a slitting bladeplunger 159. The slitting blade plunger 159 can control a sharp, linearslitting blade (not shown) at the distal end of the slitting blade case158. The slitting blade plunger 159 can be translated, as shown by arrow161, inserting the slitting blade through the heart 106 and forming aslit in the heart 106. The valve 16 and seals in the valvular structure12 can form a fluid-tight seal against the slitting blade case 158,preventing blood from flowing out of the heart 106 through the valvularstructure 12. The slitting blade case 158 can be removed from thevalvular structure 12 and the procedure site after the slit is formed.Instead of a slitting blade, the slit can be formed by a foreblade 152extended from a coring knife 140, as shown and described in FIGS. 41 athrough 41 d.

FIG. 40 c illustrates that the coring knife 140 can be translated, asshown by arrow 163, into the valvular structure 12 and attachment ring22. The coring knife 140 engages with the valvular structure 12 withlocking tabs 181 and locking slots or coupling grooves 71 to provide areliable connection and a depth marker and locator. The coring abutment145 can be inserted through the slit in the heart 106 formed by theslitting blade. The coring abutment 145 can be pushed into the leftventricle 165 while the heart 106 continues to beat. The seals and valve16 can produce a seal around the coring knife 140 preventing blood fromflowing out of the beating heart 106 through the valvular structure 12.

FIG. 40 d illustrates that the knife handle 139 can be rotated, as shownby arrow 142, rotating the coring abutment 145, as shown by arrow 149,for example, to prepare the coring knife 140 to core a portion of theheart 106. The coring abutment 145 can be in a plane substantiallyparallel with, and adjacent to, the internal side of the adjacent heartwall in the left ventricle 165.

FIG. 40 e illustrates twisting the coring blade 137 to cut a cylinder ofthe heart wall away from the rest of the heart wall. The handle can behelically moved, as shown by arrow 144, helically extending the coringblade 137, as shown by arrow 150, through the heart wall. The distaledge of the coring blade 137 can be sharpened and/or serrated and cancut the heart wall as the coring blade 137 moves through the heart wall.The coring abutment 145 can resist motion of the heart wall away fromthe coring blade 137, compressing the heart wall between the coringblade 137 and the coring abutment 145. The coring blade 137 can beextended until the coring blade 137 contacts the coring abutment 145,coring the heart wall. The heart wall can be cored coaxial (i.e., alongsubstantially the same longitudinal axis) with the valvular structure 12and/or attachment ring 22.

In an alternative variation of the coring knife 140 with the coringabutment 145 having a smaller outer diameter than the inner diameter ofthe cutting edge of the coring blade 137, the coring blade 137 can beextended until the coring blade 137 passes adjacent to the coringabutment 145, shearing the cored tissue 175 between the coring blade 137and the outer circumference of the coring abutment 145.

The coring knife 140 can be withdrawn and removed from the heart 106,attachment ring 22 and valvular structure 12 with the coring blade 137pressed against the coring abutment 145 to form a closed volume in thecoring blade 137. The core of heart tissue formed by the coring blade137 can be stored within the coring blade 137 and removed from thetarget site with the coring knife 140.

FIG. 40 f illustrates that the inflow conduit 10 of the pump 8 (pump 8not shown in FIG. 40 f) can be translated, as shown by arrow 183, intothe valvular structure 12 and the attachment ring 22. The inflow conduitstop 42 can abut and interference fit against the housing 18, stoppingtranslation of the inflow conduit 10.

The valvular structure 12 and attachment ring 22 can be de-aired byapplying suction to the de-airing port 62 of the valvular structure 12and/or injecting saline or blood into the de-airing port 62. Thevalvular structure 12 can be de-aired once during the implantation ofthe ventricular assist system or multiple times throughout theimplantation, for example immediately before and/or after insertion ofthe inflow conduit 10 through the valvular structure 12.

After the inflow port 7 of the inflow conduit 10 is located in the heart106 and/or past a fluid tight seal formed against the attachment ring 22(e.g., with the attachment ring seal 34) and/or the valvular structure12 (e.g., with the housing seal 47 and/or valve 16), the valvularstructure 12 can be removed from the attachment ring 22. For example,the first joint latch 69 can be opened, as shown by arrows 168. Thehousing first portion 46 and housing second portion 54 can then berotated open and removed from the attachment ring 22, as shown by arrows169.

FIG. 40 g illustrates the valvular structure 12 in a configuration whenbeing opened and in the process of being removed from the inflow conduit10. A first portion of the valvular structure 12 can be rotated awayfrom a second portion of the valvular structure 12. For example, theinter-leaflet seam 64 can open at a lateral perimeter surface of thevalve 16, splitting open the valve 16 along the respective housing seam51 or 49, and the housing first portion 46 can rotate open away from thehousing second portion 54 at a hinge at the housing second seam 48. Whenthe housing 18 is removed, the valve 16 can separate from the housing 18and remain on the inflow conduit 10. The valve 16 can then be rotatedopen at the end of an interleaf seam that extends to but not through thevalve shoulder 59 (with the valve shoulder 59 acting as a hinge), asshown in FIG. 40 g, and/or cut or torn at the interleaf seam and pulledaway from the inflow conduit 10. The valve 16 can be removed with thehousing 18 from the inflow conduit 10, as shown in FIG. 40 g, or afterthe housing 18 is removed from the inflow conduit 10. FIG. 40 hillustrates the inflow conduit 10 and attachment ring 22 following theremoval of the valvular structure 12. The pump 8 is not shown but isattached to the distal end of the inflow conduit 10. The inflow conduit10 can have an indicator that the pump 8 should be attached to thedistal end of the inflow conduit 10.

FIG. 40 i illustrates that the inflow conduit 10 can be furthertranslated, as shown by arrows, into the left ventricle 165. The inflowconduit 10 can be translated until the inflow conduit stop 42interference fits against the ring wall interference lip. The clamphandle 36 can then be closed, as shown by arrow 170, reducing thediameter of the clamp 24 and pressure fitting or compressing the insideof the attachment ring 22 against the outside of the inflow conduit 10,reducing or preventing translation of the inflow conduit 10 with respectto the attachment ring 22. The outside surface of the inflow conduit 10can form a fluid-tight seal against the inside surface of the attachmentring 22 for example at the attachment ring seal 34. The inflow conduit10 can be removed or repositioned, for example, by opening the clamphandle 36, removing or repositioning the inflow conduit 10, and thenclosing the clamp handle 36.

The heart 106 can pump blood during the creation of the slit, insertionof the coring abutment 145 into the ventricle, coring, insertion of theinflow conduit 10 into the heart 106, removal of the valvular structure12, tightening of the clamp 24 around the attachment ring 22, orcombinations or all of the above.

FIGS. 41 a through 41 d illustrate a method of coring a portion of theheart wall using a variation of the coring knife 140 similar to thevariation shown in FIG. 38. FIG. 41 a illustrates that the coring knife140 can be placed adjacent to a valvular structure 12 with a diaphragmvalve 16. FIG. 41 b illustrates that the coring knife 140 can beinserted through the diaphragm port 83. The diaphragm port canelastically deform to accommodate the coring knife 140 passing throughthe diaphragm port. The diaphragm can form a fluid-tight seal around thecoring knife 140 as the coring knife 140 is inserted into the diaphragmport. The foreblade 152 can be extended out of the distal end of theknife head 136 and pressed into the heart wall, as shown by arrow. Theforeblade 152 can cut or slit the heart 106. The knife head 136 can bepushed into the slit or cut in the heart wall made by the foreblade 152.

FIG. 41 c illustrates that the knife handle 139 can be translated towardthe heart 106, extending the knife head 136 into the left ventricle 165,as shown by arrow. The coring abutment 145 can be facing the innersurface of the heart wall. The foreblade 152 can be retracted to beatraumatically covered by the knife head 136.

FIG. 41 d illustrates that the knife handle 139 can be translated awayfrom the heart 106, retracting the knife head 136 toward the coringabutment 145, as shown by arrow. The coring abutment 145 and coringblade 137 can cut tissue away from the heart wall. The coring abutment145 and coring blade 137 can shear (if the coring abutment 145 has asmaller diameter than the diameter of the coring blade 137) or chop (ifthe coring abutment 145 has a diameter larger than or equal to thediameter of the coring blade 137) the tissue. Cored tissue 175 can bestored within the internal volume of the coring blade 137 until afterthe coring knife 140 is removed from the valvular structure 12. When thecoring knife 140 is removed from the valvular structure 12, thediaphragm can close, preventing or minimizing blood flow from the heart106 from exiting the valvular structure 12.

FIGS. 42 a through 42 c illustrate a method of using a valvularstructure 12 having a locking ring 98 to clamp the attachment ring 22 tothe inflow conduit 10. FIG. 42 a illustrates that the inflow conduit 10can be inserted, as shown by arrow, through the valvular structure 12having a diaphragm valve 16 (the diaphragm can be elastically deformedout of the way of the inflow conduit 10 but is not shown forillustrative purposes). The diaphragm port 83 can elastically expand toaccommodate the inflow conduit 10. The diaphragm port 83 can form afluid-tight seal around the inflow conduit 10, preventing blood fromflowing from the heart 106 out the valvular structure 12.

FIG. 42 b illustrates that the tape 89 can then be removed from thevalvular structure 12. The housing 18 can then be separated into thehousing first portion 46 and the housing second portion 54 componentsand removed from the target site. The diaphragm valve 16 can then beremoved, such as by being torn or cut away from the inflow conduit 10 orremoved with the housing 18 when the diaphragm seam 88 opens.

FIG. 42 c illustrates that the locking ring 98 can be forced toward theheart 106, as shown by arrow. In the configuration shown in FIG. 42 c,the locking ring 98 can compress the ring wall 29. The inner diameter ofthe ring wall 29 can be reduced by the compressive pressure from thelocking ring 98. The radially inner surface of the attachment ring wall29 can compress against and press-fit to the radially outer wall of theinflow conduit 10, forming a fluid-tight seal. The locking ring 98 canbe pulled away from the heart 106, relaxing and expanding the attachmentring wall 29, for example reducing the force of or completelyeliminating the press fit between the radially inner surface of theattachment ring wall 29 and the radially outer surface of the inflowconduit 10.

FIGS. 43 a and 43 b illustrate a variation of a method for de-airing theoutflow conduit 2. FIG. 43 a illustrates that when the blood flow in theoutflow conduit 2 is stanched by a clamp 131 (as shown) or balloon 135,a balloon catheter 132 can be inserted through the wall of the outflowconduit 2. The pump 8 can be de-aired, for example the pump 8 can be runwhen in fluid communication with the ventricle, or the pump 8 can bepre-loaded with saline or blood. The balloon 135 can then be insertedinto the terminal outflow end of the pump 8 and inflated, for examplemaintaining the pump 8 and inflow conduit 10 in a de-aired condition(i.e., with no air within the fluid channel of the pump 8 or the inflowconduit 10).

FIG. 43 b illustrates that the outflow conduit 2 can be joined to thepump 8 at the outflow conduit coupler 4. The clamp 131 can be removedfrom the outflow conduit 2 before coupling the outflow conduit 2 to thepump 8, allowing blood from the aorta 104 to de-air the outflow conduit2 and then the outflow conduit 2 can be joined to the pump 8.

Alternatively, the outflow conduit clamp 131 can remain on the outflowconduit 2 after the outflow conduit 2 is joined to the pump 8. Theballoon 135 can then be removed from the pump 8 and outflow conduit 2,and the pump 8 can be run. The air from the outflow conduit 2 betweenthe outflow conduit clamp 131 and the pump 8 can be forced out throughthe hole in the side wall of the outflow conduit 2 directly or drawn outvia a needle inserted into the outflow conduit 2. If a balloon catheterwith side ports is used, the catheter ports can be used to withdraw airinstead of using the hole in the graft or an additional needle.

Once the outflow conduit 2 and the remainder of the system is de-aired,the balloon 135 (as shown) and/or outflow conduit clamp 131 can beremoved from the outflow conduit 2. If a catheter 132 was removed fromthe wall of the outflow conduit 2, a suture can be sewn if needed, suchas by a purse stitch, into the outflow conduit 2 to close the hole inthe outflow conduit wall.

Alternatively, when the outflow conduit 2 is occluded by the balloon 135or clamp 131, the pump 8 can be attached to the outflow conduit 2 andoperated. Excess air in the ventricular assist system can be withdrawnwith a catheter 132 or the bi-material balloon described herein.

FIG. 44 illustrates another variation of a method for de-airing thesystem using a liquid-filled de-airing bladder, enclosure or pouch toprevent air from entering the VAD components during assembly of theoutflow conduit 2 and the pump 8. The outflow conduit coupler 4, outflowend of the pump 8 and the end of the outflow conduit 2 to be attached tothe pump 8 can be placed in the de-airing pouch 179. The de-airing pouch179 can be filled with saline before or after placing the VAD componentsin the de-airing pouch 179. The attachment ring 22 can be previouslyde-aired through the de-airing port 62 on the valvular structure 12. Theoutflow conduit 2 can be previously de-aired with blood flow from theaorta 104 and stanching, for example, with an outflow conduit clamp 131or balloon 135. The pump 8 and inflow conduit 10 can be pre-filled withsaline or blood before delivery into the target site. The outflow portof the pump 8 can be plugged before the pump 8 is delivered into thetarget site.

When the outflow end of the pump 8 and the inflow end of the conduit arelocated in the de-airing pouch 179, the balloon 135 in the outflowconduit 2 can be deflated and removed or the outflow conduit clamp 131on the outflow conduit 2 can be removed. The blood flowing from theaorta 104 can de-air the outflow conduit 2, purging air in the outflowconduit 2 into the de-airing pouch 179. The purged air can then escapefrom the de-airing pouch 179 or travel to a portion of the de-airingpouch 179 away from the openings of the VAD components. The pump 8 canbe driven to pump blood through the inflow conduit 10 and pump 8 todrain any additional air from the pump 8 and inflow conduit 10. Theoutflow conduit 2 can then be attached to the pump 8 in the de-airingpouch 179 or without a de-airing pouch 179, as shown in FIG. 43 b or 45.

The percutaneous lead 5 can be attached to the pump 8 and to externalpower, control and data transmission devices as known in the art.

The system can be implanted when the heart 106 is beating and thepatient is not on cardio-pulmonary bypass. However, the system can beimplanted with the patent on cardio-pulmonary bypass and the heart 106slowed or stopped. The system can be implanted using less invasivetechniques described herein, but can be implanted with a fullthoracotomy and sternotomy.

In FIGS. 46 a and 46 b, another embodiment of attachment ring 22 isformed by injection molding a polymer in a mold containing reinforcementelements which are to be imbedded or encased within the polymer. Themold cavity includes geometric features that simultaneously forminterface lip 25, cylindrical ring wall 29 which forms a tubular fluidpassageway, distal band 31, and ring seal 34 as a single, unitarystructure. Ring seal 34 forms the circular, inner edge of the proximalopening to ring channel 14.

Attachment ring 22 is flexible. The polymer used for molding can besilicone rubber, although other polymers suitable for implantation maybe used. When completely cooled and/or cured after molding, the polymeris flexible and elastic to allow ring seal 34 to flex, conform, and sealagainst a cylindrical object that is inserted through ring channel 14.The reinforcement elements include proximal reinforcement band 202,distal reinforcement band 204, and fiber mesh 206. Proximal and distalreinforcement bands 202, 204 can be made of a material that is morerigid than the polymer injected into the mold and which forms theremainder of attachment ring 22. The additional rigidity providedproximal and distal reinforcement bands 202, 204 help openings at theopposite ends of ring channel 14 maintain a circular shape. Proximal anddistal reinforcement bands 202, 204 can be made of Nylon, acetal,polycarbonate, HDPE, PP, PET, PEEK, titanium or stainless steel. Fibermesh 206 can be made of polyester fibers that have been braided to forma mesh tube which is then placed in the mold as part of the moldingprocess. Other types of fibers and mesh configurations can be used.Fiber mesh 206 can be distributed within distal band 31 and ring wall29. Fiber mesh 206 helps prevent the polymer from tearing due tomechanical stress, such as may be arise from sutures used later toattach cuff 35 to distal band 31. Flared ends of fiber mesh 206 providepositive fixation of sutures to the polymer substrate of distal band 31.

Attachment ring 22 can be rotationally symmetric about longitudinal axis200, so that interface lip 25, ring wall 29, distal band 31, ring seal34, proximal reinforcement band 200, and distal reinforcement band 202are each annular in shape.

After molding, cuff 35 can be attached to distal band 31 by passing aneedle with suture 208 through cuff 35 and distal band 31. Suture 208can be a continuous, non-bioerodable fiber or thread that is looped in ahelical manner through the outer perimeter of distal band 31. Oppositeends of suture 208 can be tied in a knot 208 a to prevent loosening.Portion 29 a of ring wall 29 extends distally beyond distal band 31.Portion 29 a helps to center the hole in cuff 35 with ring channel 14 sothat no portion of cuff 35 obstructs ring channel 14. In subsequentclinical use of attachment ring 22, cuff 35 is attached to a patient'sheart and ring clamp 24 can be used to secure inflow conduit 10 withinring channel 14.

The molding process allows ring seal 34 to be formed, in a consistentmanner, with a diameter and round shape that corresponds to the size ofinflow conduit 10, so that a fluid-tight seal between attachment ring 22and exterior surfaces of inflow conduit 10 results when inflow conduit10 is disposed within attachment ring 22

In FIGS. 47 a-47 c, another embodiment of attachment ring 22 is formedby molding a polymer into a sheet in which fiber mesh 206 is embedded orencased. Suitable materials for the polymer and fiber mesh can be asdescribed for FIGS. 46 a-46 d. As shown in FIGS. 47 a and 47 b,attachment ring 22 can be made by cutting out a rectangular strip 210from the flat sheet, rolling strip 210 so that opposite ends 212 of thestrip overlap, and bonding ends 212 together to form a fluid-tight seam214.

Next, cuff 35 can be attached around distal portion 216 of the rolledstrip by passing a needle with suture 208 through cuff 35 and distalportion 216. A single, continuous piece or several pieces of suture 208can be used to secure proximal edge 218 and distal edge 220 of cuff 35to distal portion 216 of the rolled strip. In subsequent clinical use ofattachment ring 22, cuff 35 is attached to a patient's heart and ringclamp 24 can be used to secure inflow conduit 10 within ring channel 14.Interior edge 214 a of seam 214 extends through the entire length ofring channel 14. End 212 a of the strip which forms interior edge 214 acan be tapered in cross-section so as to form a smooth interface withopposite end 212 b. Material can also be added at interior edge 214 a toform the smooth interface. The smooth interface allows the inner surfaceof ring channel 14 to form a fluid-tight seal against inflow conduit 10.

In FIGS. 48 a and 48 d, another embodiment of attachment ring 22 isformed by injection molding a polymer in a mold cavity having geometricfeatures that simultaneously form ring wall 29, distal band 31, ringseal 34, and ring valve 230 as a single, unitary structure. Suitablematerials for the polymer can be as described for FIGS. 46 a-46 d. FIGS.48 a and 48 c show views of the distal end and proximal end,respectively. FIGS. 48 a and 48 b show attachment ring 22 without cuffto better show features of distal band 31.

Attachment ring 22 can be rotationally symmetric about longitudinal axis200, so ring wall 29, distal band 31, and ring seal 34 are each annularin shape. In the illustrated embodiment, ring valve 230 is a quadcuspid(i.e., four-leaflet) valve similar in configuration to valve 16described in connection with FIGS. 12 a and 15 c. Other configurationsfor valve 230 can be implemented, for example and without limitation atricuspid valve (similar to FIG. 14 a), a bicuspid valve (similar toFIG. 15 a), a dome valve, a diaphragm valve (similar to FIG. 15 f), andcombinations thereof. Ring seal 34 forms the circular, inner edge of theproximal opening of ring channel 14. When a cylindrical object (forexample, slitting tool 300 and coring knife 140) is inserted into theproximal opening of ring channel 14, ring seal 34 seals against thecylindrical object and ring valve 230 flexes open. When the cylindricalobject is removed, ring valve 230 closes autonomously to reduce, preventor inhibit fluid from flowing distally through ring valve 230 in thedirection of arrow 231. With attachment ring 22 attached to the heart,ring valve 230 can allow slitting and coring of heart tissue while theheart is beating and pumping without the use of valvular structure 12.

After molding, cuff 35 can be attached to distal band 31 by passing aneedle with suture 208 through cuff 35 and distal band 31, such asdescribed for FIGS. 46 c and 46 d. In subsequent clinical use ofattachment ring 22, cuff 35 is attached to a patient's heart and ringclamp 24 can be used to secure inflow conduit 10 within ring channel 14.

Attachment ring 22, in any of the embodiments described above, mayinclude an alignment feature that allows a slitting tool and coringknife 140 to share common alignment. A slitting tool is shown in FIGS.52 a-52 c. In use, the slitting tool can be inserted into attachmentring 22. When inserting the slitting tool into attachment ring 22, thealignment feature ensures that the flat blade of the slitting tool isoriented in a particular way, as will be described in more detail below.Once aligned, the flat blade extends to form a slit in the heart tissue,then the slitting tool is removed from attachment ring 22. The slitfunctions as a passage through which elements of coring knife 140 can beinserted. When inserting coring knife 140 into attachment ring 22, thealignment feature ensures that rotatable coring abutment 145, such asshown in FIGS. 37 a-37 d, is oriented along the same line as the slitpreviously formed by the slitting tool and thereby allows of easy entryof coring abutment 145 into the heart cavity.

Alignment feature can take the form of a structural feature, such as twoindentations 230 (FIG. 4 a) formed into interface lip 25 at the proximalend of attachment ring 22. Indentations 230 can be shaped and sized toreceive protrusions 346 on the exterior surface of the slitting tool(see FIG. 52 a) and protrusions 411 on the exterior surface of thecoring knife (see FIG. 54). Indentations 230 allow for “blind” alignmentwhereby engagement of indentations and protrusions provide tactilefeedback to the surgeon or other user which indicates proper alignment.Alignment feature can also take the form of a visual indicator, such asindelible markings 232 (FIG. 46 c) in a contrasting color and/or anembossed marking applied on interface lip 25. In use, a pair ofprotrusions or markings on the exterior surface of the slitting tool canbe aligned with markings 232 during insertion of the slitting tool intoattachment ring 22. Subsequently, a pair of protrusions or markings onthe exterior surface of coring knife 140 can be aligned with markings232 during insertion of coring knife 140 into attachment ring 22.

Referring again back to FIG. 7 a, clamp 24 can be disposed around thecentral portion of attachment ring wall 29 located between interface lip25 and cuff 35. Clamp 24 can be installed and removed from attachmentring 25 by translating it axially, in a direction along longitudinalaxis 200, onto attachment ring 22 until it reaches the central portionof attachment ring wall 29. However, in cases where clamp 24 has limitedability enlarge its clamp diameter 38, interface lip 25 and cuff 35could interfere with axial translation of attachment ring 22, makinginstallation and removal of attachment ring 22 difficult especiallyafter attachment ring 22 has been secured to heart tissue.

In FIGS. 49 a-49 d, another embodiment of clamp 24 is shown havingmultiple linkages that allow clamp 24 to be easily installed and removedfrom attachment ring 22, either before or after attachment ring 22 hasbeen secured to heart tissue. The linkages are in the form of firstcurved piece 240, second curved piece 242, lever 244, and third curvedpiece 246. When clamp 24 is closed (FIG. 49 a), inner surfaces of first,second and third curved pieces 240, 242, 246 form a circle havingdiameter 247 needed to allow the curved pieces to apply pressure toattachment ring wall 29 in order to secure inflow conduit 10 toattachment ring 22. Diameter 247 can be about the same as or slightlysmaller (for example, 5%, 10%, or 20% smaller) than the outer diameterof attachment ring wall 29. The linkages can be pivoted relative to eachother so as to create an opening that is larger that the outer diameterof attachment ring wall 29. With this ability, attachment ring 22 can beinstalled and removed from attachment ring 22 in a manner that avoidsinterference from interface lip 25 and cuff 35.

Referring to FIG. 49 b, the ends of first curved piece 240 and secondcurved piece 242 are pivotally connected to each other by primary hinge241. The opposite end of first curved piece 240 has hook 245. Theopposite end of second curved piece 242 is connected to lever 244 byfirst lever hinge 248. Second lever hinge 250 connects medial part 252of lever 244 to one end of third curved piece 246. Medial part 252 isdisposed between two legs 254 of third curved piece 246. The oppositeend of curved piece 246 has cylindrical catch 256. Cylindrical catch 256connects legs 254 together and is sized and shaped to fit within hook245.

FIG. 49 a shows clamp 24 when closed. Lever 244 is disposed withingroove 243 (FIG. 49 b) formed within second curved piece 242 and betweenlegs 254 of third curved piece 246. Cylindrical catch 256 is seatedwithin hook 245. First lever hinge 248 is positioned adjacent hook 245.

When clamp 24 is closed, movement of third curve piece 246 along thedirection of arrow 260 is prevented by the presence of attachment ringwall 29 and inflow conduit 10 within clamp 24. That is, attachment ringwall 29 and inflow conduit 10 prevent inner diameter 247 of clamp 24from getting smaller.

To open clamp 24, a person can pull protrusion 258 at the free end oflever 244 radially outward in the direction of arrow 262, as shown inFIG. 49 b. Movement of protrusion 258 along arrow 260 causes cylindricalcatch 256 to move along arrow 260, without requiring inner diameter 247to get smaller. Thus, the presence of attachment ring wall 29 and inflowconduit 10 within clamp 24 does not prevent cylindrical catch 256 fromdisengaging hook 245 when protrusion 258 is pulled along arrow 260. Oncedisengaged first curve piece 240 can be pivoted about primary hinge 241to create an opening that is substantially larger than diameter 247, asshown in FIG. 49 c.

Clamp 24 can have a provision for locking lever 244 in the closedposition. Through hole 264 is formed through the free end of lever 244.When in the closed position, as shown in FIG. 49 a, first opening 266 ofthe through hole is exposed and second opening 268 (FIG. 49 b) isdisposed within groove 243 in second curved piece 242. Second opening268 faces the opening of through hole 267 in second curved piece 242which extends to the outer surface of second curved piece 242. Throughhole 264 and through hole 267 can be aligned so as to be coaxial, whichallows a suture to be looped through both through holes. The sutureprevents lever 244 from moving out in direction of arrow 262 and therebykeeps clamp 24 closed. Opposite ends of the suture can be tied togetherin a knot to keep the suture in place. The suture can be cut to allowits removal and to allow clamp 24 to be opened.

In FIGS. 50 a and 50 b, another embodiment of clamp 24 is shown having asingle, unitary structure in the form of ring 270 with detachable ends.The ends have ratchet features that interlock with each other and allowinner diameter 272 of ring 270 to become smaller. First end 274 includesguard member 276 and ratchet member 278 with a plurality of radiallyinward facing teeth 280. Second end 282 includes ratchet member 284 witha plurality of radially outward facing teeth 286. Ratchet member 284 isdisposed within an open channel between guard member 276 and ratchetmember 278. When clamp 24 is open, as shown in FIGS. 50 a and 50 b, gap280 exists between the free end of ratchet member 284 and the end of theopen channel between guard member 276 and ratchet member 278. Gap 280allows first end 274 and second end 282 to pushed together, which causesteeth 280 and teeth 286 to engage each other. Teeth 280 and teeth 286are configured to slip past each other when first end 274 and second end282 are pushed together and are configured to engage each other toprevent first end 274 and second end 282 from subsequently moving apartfrom each other. In use, clamp 24 can be disposed around attachment ringwall 29 of attachment ring 22. Guard member 276 prevents attachment ringwall 29 from being pinched within gap 280.

Ring 270 functions like a spring in that it stores spring energy whenfirst end 274 and second end 282 are pushed together. Ring 270 can beformed by injecting a polymer into a mold cavity that includes geometricfeatures that simultaneously form guard member 276, ratchet member 278,teeth 280, ratchet member 284, and teeth 286 as a single, unitarystructure. Through hole 288 is formed in first end 274. Through hole 290is formed in second end 282. Through hole 288 and through hole 290 canreceive tips of a tool for pushing first end 274 and second end 282together. Through hole 300 is formed in ratchet member 278. Opposingteeth 280, 286 can be disengaged from each other by inserting a tool inthrough hole 300 and pulling radially outward. When opposing teeth 280,286 disengage, first end 274 and second end 282 autonomously move apartfrom each other due to the spring energy stored in ring 270.

After pushing first end 274 and second end 282 together, a suture can belooped into through hole 300 and through hole 290 as a security measureto prevent the ratchet members from inadvertently disengaging. Oppositeends of the suture can be tied together in a knot to keep the suture inplace. The suture can be cut to allow its removal and to allow ratchetmembers to disengage and inner diameter 272 to enlarge.

When clamp 24 is open, as shown in FIGS. 50 a and 50 b, inner diameter272 is larger than the outer diameter of attachment ring wall 29 ofattachment ring 22. When clamp 24 is closed by pushing the first end 274and second end 282 together, inner diameter 272 corresponds to the sizeof inflow conduit 10 plus the thickness of attachment ring wall 29, sothat a fluid-tight seal between attachment ring 22 and exterior surfacesof inflow conduit 10 results when inflow conduit 10 is disposed withinattachment ring 22.

In FIG. 51, another embodiment of clamp 24 is shown having ratchetmembers 278, 284, each with only one tooth 286, 280. Other embodimentsmay have any number of teeth, as may be needed, to provide additionalengagement and/or to allow clamp 24 to be used with attachment rings 22and inflow conduits 10 of different sizes.

After attachment ring 22 is attached to heart apex 119, foreblade 152 ofcoring knife 140 of FIG. 38 can be used to form a slit through theepicardium and into the myocardium at heart apex 119. Alternatively,slitting tool 300 of FIGS. 52 a-52 c can be used to form the slit intothe heart.

As shown in FIG. 52 a, cylindrical housing 302 has front end 304 andrear end 306. Rear end 306 includes radially protruding handles 308.Spring-loaded actuator 310 protrudes axially out of rear end 306 and isconnected to a flat blade contained within housing 302. Pushing actuator310 axially forward in the direction of arrow 312 causes the flat bladeto extend out of slit opening 314 at front end 304.

As shown in FIG. 52 b, spring 316 is contained within a rear segment ofhousing 302. Rear end 318 of spring 316 is attached to a medial segmentof actuator 310. Forward end 320 of spring 316 abuts wall 322 withinhousing 302. Spring 316 and flat blade 326 are contained within housing302 at opposite sides of wall 322. Spring 316 is under compression andkeeps the flat blade completely retracted within housing 302 until auser pushes actuator 310. Actuator 310 extends through a hole in wall322. Forward end 324 of actuator 310 is connected to flat blade 326. Asactuator 310 is translated forward in the direction of arrow 312,actuator 310 compresses spring 316 against wall 322 and forward end 324pushes blade 326 out of front end 304 of housing 302.

FIG. 52 c shows flat blade 326 extending out of slit opening 314 afteractuator 310 has been pushed forward. Blade seal 328 is contained withinhousing 302 and is located adjacent slit opening 314 at front end 304.Flat blade 326 passes through blade seal 328 which includes a pair offlexible wipers 330 that face each other. Wipers 330 extend across theentire blade width 332 (FIG. 52 b) and press against opposite sides offlat blade 326, thereby preventing blood from flowing into the rearsegment of housing 302. Blade seal 328 can be made of silicone rubber orother resilient polymer. In other embodiments, blade seal 328 is a stripof polymer foam with a slit equivalent in size to blade width 332.

In use, front end 304 of housing 302 is inserted into attachment ring 22or the combination of valvular structure 12 and attachment ring 22.Outer diameter 331 of housing 302 and ring seal 34 of attachment ring 22can be sized such that a substantially fluid-tight seal is formedbetween the exterior surface of housing 302 and ring seal 304 when frontend 304 is inserted into through attachment ring 22. When flat blade 326punctures a beating heart and is retracted, blood from the heart mayflow into attachment ring 22 and into slit opening 314 of housing 302.Blade seal 328 minimizes blood loss by preventing or inhibiting bloodfrom flowing through and out of slitting tool 300.

In some embodiments, outer diameter 331 of housing 302 and housing seal47 (FIG. 10 a) of valvular structure 12 can be sized such that asubstantially fluid-tight seal is formed between the exterior surface ofhousing 302 and housing seal 47 when front end 304 is inserted intovalvular structure 12 which has been attached to attachment ring 22.When flat blade 326 punctures a beating heart and is retracted, bloodfrom the heart may flow into attachment ring 22, valvular structure 12,and slit opening 314 of housing 302. Blade seal 328 minimizes blood lossby preventing or inhibiting blood from flowing through and out ofslitting tool 300.

Referring again to FIG. 52 a, stop feature 340 is located on housing 320at a predetermined distance 342 from the forward most tip 344 ofslitting tool 300. Stop feature 340 prevents tip 344 from pushing intothe heart when slitting tool 340 is being positioned within attachmentring. Stop feature 340 includes a pair of protrusions 346 sized andshaped to fit within alignment features on attachment ring 22 and/orvalvular structure 12.

In some embodiments, predetermined distance 342 is equivalent to or afew millimeters less than the longitudinal height of attachment ring 22.The longitudinal height can be the maximum dimension as measured alongthe longitudinal axis of attachment ring 22. The longitudinal height ofan exemplary attachment ring is indicated by arrow 348 in FIG. 46 d. Inuse, slitting tool 300 can be inserted by a surgeon or other user intoattachment ring 22 secured to the heart, with no valvular structure 12attached to attachment ring 22. When stop feature 304 abuts interfacelip 25 of attachment ring 22, the user will know that tip 344 ofslitting tool 300 is located at the proper position just above theheart. The user can twist slitting tool 300 about its central axis 301until protrusions 346 become seated within indentations 230 (FIG. 4 a)formed into interface lip 25. When protrusions 346 engage indentations230, the user will know from tactile feed back that slitting tool 300 isin proper rotational alignment. Thereafter, the user can extend flatblade 326 to make a slit through the heart, and then use coring knife140 under the same rotational alignment as slitting tool 300 to form acircular hole around the slit.

In some embodiments, predetermined distance 342 is equivalent to or afew millimeters less than the longitudinal stack height of valvularstructure 12 and attachment ring 22. The longitudinal stack height of anexemplary assembly of valvular structure 12 and attachment ring 22 isindicated by arrow 350 in FIG. 2 b. In use, slitting tool 300 can beinserted by a surgeon or other user into valvular structure 12 andattachment ring 22 which has been attached to the heart. When stopfeature 304 abuts the proximal end of valvular structure 12, the userwill know that tip 344 of slitting tool 300 is located at the properposition just above the heart. The user can twist slitting tool 300about its central axis 301 until protrusions 346 become seated withinalignment features (for example, coupling grooves 71 (FIG. 11 a) formedinto the proximal end of valvular structure 12. When protrusions 346engage the alignment features, the user will know from tactile feed backthat slitting tool 300 is in proper rotational alignment. Thereafter,the user can extend flat blade 326 to make a slit through the heart, andthen use coring knife 140 under the same rotational alignment asslitting tool 300 to form a circular hole around the slit.

Stop feature 340 can be an annular flange, as illustrated, which can bean integral part of or permanently affixed to housing 320. Protrusions346 can be spaced 180 degrees apart from each other on the circumferenceof stop feature 340. Alternatively, stop feature 304 can be movablealong housing 302 to allow predetermined distance 342 to be adjusted ifdesired.

In FIGS. 53 a-53 f, another embodiment of coring knife 140 is shownhaving pistol-type grip 360, release trigger 362, and abutment controllever 364. FIG. 53 a shows coring knife 140 in its startingconfiguration, in which the plane of coring abutment 145 is in line withlongitudinal axis 366 of coring knife 140, and coring blade 137 iscompletely contained within coring knife case 141. The plane of thecoring abutment 145 is defined by a plurality of points on the outerperimeter of coring abutment 145. Coring abutment 145 is held inposition by two support rods 368. Control arm 146 is disposed betweensupport rods 368. Support rods 368 and control arm 146 extend into theforward end of slide assembly 370 and into central shaft 372 (FIG. 53 d)which is fixedly attached to grip 360. The forward ends of support rods368 and control arm 146 are pivotally connected to different points oncoring abutment 145. Control arm 146 is operatively coupled to abutmentcontrol lever 364.

As shown in FIG. 53 b, the forward ends of support rods 368 are attachedto coring abutment 145 at points 372 that form pivot line 374 that issubstantially perpendicular to longitudinal axis 366. The forward endsof support rods 368 can be attached to coring abutment 145 by a slenderpin that extends within coring abutment 145. Control arm 146 is attachedto coring abutment 145 at point 376 which is longitudinally offset byoffset distance 377 from points 372 so as to be closer to forward mosttip 378 of coring abutment 145. The forward end of control arm 146 canbe attached to coring abutment 145 by another slender pin that extendswithin coring abutment 145. Due to offset distance 377, movement ofcontrol arm 146 rearward in the direction of arrow 380, while supportrods 368 remain stationary, causes coring abutment 145 to rotate aboutpivot line 374. As shown in FIG. 53 c, when point 376 has moved rearwardby a distance equivalent to offset distance 377, the plane of coringabutment 145 is substantially perpendicular to longitudinal axis 366.Control arm 146 is operatively coupled to control lever 364 which ispivotally attached to grip 360. As shown in FIG. 53 d, pivoting controllever 364 upward in a direction along arrow 382 causes control arm 146to move rearward along arrow 380 until the plane of abutment surface 145is substantially perpendicular to longitudinal axis 366. Control lever364 includes safety latch 384. When control lever 364 is in a loweredposition (FIG. 53 a), safety latch 384 is in front of knob 385 of slideassembly 370 where it prevents slide assembly 370 from inadvertentlysliding toward coring abutment 145. When control lever 364 is in araised position (FIG. 53 d), safety latch 384 has moved away from knob385 and slide assembly 370 can slide toward coring abutment 145 whenrelease trigger 362 is pressed by the user.

Slide assembly 370 comprises coring blade 137, coring knife case 141,and internal sleeve 386. Internal sleeve 386 (FIG. 53 f) is disposedaround and slides longitudinally over central shaft 372. Coring knifecase 141 is fixedly attached to internal sleeve 386. Internal sleeve 386includes a pair of linear slots 388 (FIG. 530 which extend substantiallyparallel to longitudinal axis 366. Pin 390 (FIG. 53 e) protrudes fromcentral shaft 372 into linear slots 388 and thereby prevents internalsleeve 386 from rotating relative to central shaft 372 and grip 360. Pin390 prevents internal sleeve 386 from rotating relative to central shaft372. Internal sleeve 386 also includes a series of holes 392 arrangedalong one or more lines substantially parallel to longitudinal axis 366.A ball detent mechanism within central shaft 372 engages one or more ofthe holes 392 to prevent slide assembly 370 from sliding freely oncentral shaft 372. Ball detent mechanism is operatively coupled torelease trigger 362. Release trigger 362 is spring loaded in such a waythat ball detent mechanism prevents slide assembly 370 from sliding whenno force is applied to release trigger 362.

When a force is applied by a user to depress release trigger 362, balldetent mechanism disengages holes 392. The user may then grasp slideassembly 370 and slide it forward toward coring abutment 145, as shownin FIG. 53 e. In use, slide assembly 370 is preferably moved forward toa point where forward edge 396 of coring knife case 141 touches or isjust above the heart tissue 398. It is understood that coring knife case141 is now located within the ring channel 14 of attachment ring 22 orvalvular structure 12 combined with attachment ring 22. It is alsounderstood that the coring abutment 145 is located within the heartcavity and abuts the heart tissue from the side opposite coring knifecase 141. When forward edge 396 of coring knife case 141 is at thedesired position, the user may let go of release trigger 362 so thatball detent mechanism engages holes 392 and locks in the longitudinalposition of coring knife case 141.

At this stage, coring blade 137 remains completely retracted withincoring knife case 141. Coring blade 137 is a hollow cylinder the forwardend of which forms sharp circular tip 400. The rear end of coring blade137 is fixedly attached to the front end of rotatable control sleeve402. Helical coring guide or slot 147 is formed into the rear segment ofrotatable control sleeve 402. Knob 385 is fixedly attached to the rearend of control sleeve 402. Manual rotation of knob 385 by the usercauses control sleeve 402 and coring blade 137 to rotate relative tocoring knife case 141 and internal sleeve 386 which are held stationaryby ball detent mechanism and pin 390. Guide peg 148 protrudes fromcoring knife case 141 into helical slot 147 of control sleeve 402. Thus,rotation of knob 385 simultaneously causes control sleeve 402 and coringblade 137 to translate longitudinally toward coring abutment 145.Rotation in the reverse direction causes control sleeve 402 and coringblade 137 to translate longitudinally away from coring abutment 145. Itis understood that knob 385 allows the user to have complete control ofthe force applied by coring blade and complete control of coring bladeadvancement by each turn of knob 385. In this embodiment, there is nospring loading on coring blade 137 that might otherwise remove completecontrol of applied force from the user.

In FIG. 53 f, knob 385 has been rotated until circular tip 400 of coringblade 137 has pressed against coring abutment 145. In use, coring blade137 would have made a circular cut entirely through the myocardium. Around piece of polymer foam, absorbent material, or resilient material,can be disposed within the rear end of the coring blade 137 to sealaccess holes for support rods 368 and control arm 146, and thereby stopor soak up blood and prevent blood from rushing into the rear portionsof coring knife 140. A cylindrical portion of the myocardium would becompletely detached from the remainder of the heart and contained withincoring blade 137. The user may then pull coring knife 140 rearward, in adirection substantially parallel to longitudinal axis 366, therebyextracting the cylindrical portion of the myocardium out from beneathattachment ring 22 or the combination of valvular structure 12 andattachment ring 22. If the procedure is performed while the heart isbeating, either ring valve 230 (FIG. 48 b) of attachment ring 22 orvalve 16 (FIG. 2 a) of valvular structure 12 autonomously close aftercoring knife 140 is pulled out and thereby prevents significant loss ofblood.

Use of coring knife 140 can begin by inserting coring abutment 145oriented as shown in FIG. 53 a into the slit previously formed byslitting tool 300. To facilitate insertion into the slit, the plane ofthe coring abutment 145 should be aligned in the same direction as theslit. Establishing the proper alignment can be difficult because thevisual line of sight to the slit could be obstructed by the coring knifeitself, by ring valve 230 (FIG. 48 b) of attachment ring 22, or by valve16 (FIG. 2 a) of valvular structure 12. An alignment feature on theproximal end of attachment ring 22 or valvular structure 12 can be usedby the user to align coring abutment 145 to the slit in the heart. Thealignment feature can be in the form of indentations 230 (FIG. 4 a)formed into interface lip 25 at the proximal end of attachment ring 22and/or indelible markings 232 (FIG. 46 c) in a contrasting color appliedon interface lip 25. The alignment feature can be in the form ofcoupling grooves 71 (FIG. 11 a) or alignment groove 497 formed into theproximal end of valvular structure 12 or be in the form of indeliblemarkings applied to the proximal end of valvular structure 12. Acorresponding feature on coring knife case 141, such as a protrusionand/or indelible markings, can be visually aligned or physically engagedwith the alignment feature on attachment ring 22 or valvular structure12.

As previously discussed, while the user depresses release trigger 362,slide assembly 370 can be moved forward to a point where forward edge396 of coring knife case 141 touches or is just above the heart tissue398. Positioning forward edge 396 to the desired position relative tothe surface of the heart may be difficult to perform visually if theline of sight to the heart surface is obstructed by coring knife 140,valvular structure 12, and/or attachment ring 22.

As shown in FIG. 54, stop feature 410 can be located on coring knifecasing 141 at a predetermined distance 412 from forward edge 396 ofcoring knife case 141. Stop feature 410 prevents forward edge 396 frompushing into the heart when slide assembly 370 is being positionedwithin attachment ring 22. Stop feature 410 can include protrusions 411sized and shape to fit within the alignment feature on attachment ring22 or valvular structure 12, and/or can include indelible markings foraligning coring abutment 145 with the slit in the heart.

In some embodiments, predetermined distance 412 is equivalent to or afew millimeters less than the longitudinal height of attachment ring 22.The longitudinal height of an exemplary attachment ring is indicated byarrow 348 in FIG. 46 d. In use, coring knife 140 can be inserted by asurgeon or other user into attachment ring 22 secured to the heart, withno valvular structure 12 attached to attachment ring 22. When stopfeature 410 abuts interface lip 25 of attachment ring 22, the user willknow that forward edge 396 of coring knife case 141 is located at theproper position. Thereafter, the user can let go of release trigger 362to lock coring knife case 141 in place, then rotate knob 385 to extendcoring blade 137 out of coring knife case 141 and into the heart.

In some embodiments, predetermined distance 412 is equivalent to or afew millimeters less than the longitudinal stack height of valvularstructure 12 and attachment ring 22. The longitudinal stack height of anexemplary assembly of valvular structure 12 and attachment ring 22 isindicated by arrow 350 in FIG. 2 b. In use, coring knife 140 can beinserted by a user into valvular structure 12 and attachment ring 22which has been attached to the heart. When stop feature 410 abuts theproximal end of valvular structure 12, the user will know that forwardedge 396 of coring knife case 141 is located at the proper position.Thereafter, the user can let go of release trigger 362 to lock coringknife case 141 in place, then rotate knob 385 to extend coring blade 137out of coring knife case 141 and into the heart.

Stop feature 410 can be an annular flange which can be an integral partof or permanently affixed to coring knife casing 141. Alternatively,stop feature 410 can be movable along coring knife casing 141 to allowpredetermined distance 412 to be adjusted if desired.

Referring again to FIG. 54, coring abutment 145 has abutment surface 414that is substantially flat or planar. Abutment surface 414 faces coringknife case 141 after control lever 364 has been pivoted upward. In use,abutment surface 414 supports the interior surface of the heart ascoring blade 137 rotates, extends out of coring knife case 141, and cutsfrom the exterior surface of the heart. Coring blade 137 ultimatelypresses against abutment surface 414 when cutting is complete.

In other embodiments, such as shown in FIG. 55, abutment surface 414 hasa raised central portion 416 and tapered edges 418 at the outercircumference of coring abutment 145. As coring blade 137 rotates andmoves closer to abutment surface 414, raised central portion 416 entersinto coring blade 137 and tapered edges 418 abut forward edge 396 ofcoring blade. Raised central portion 416 and tapered edges 418 align thecenter of abutment surface 414 with the center of forward edge 396 ofcoring blade 137. Raised central portion 416 and tapered edges 418prevent misalignment in which a portion of forward edge 396 extendsbeyond the outer circumference of coring abutment 145 and fails to pressagainst abutment surface 414. Abutment surface 414 can be convex,spherical, conical or other shape having raised central portion andtapered edges.

In FIGS. 56 a-56 d, an embodiment of coring knife 140 is shown having anin-line grip configuration instead of a pistol-type grip. The coringknife of FIGS. 56 a-56 d has structural elements that are labeled withthe same reference numerals as those of FIGS. 53 a-53 f and 54. Thosestructural elements have the same function as those described inconnection with FIGS. 53 a-53 f and 54. The operational steps of FIGS.56 a-56 d correspond to those of FIGS. 53 a and 53 d-53 f.

Referring to FIGS. 56 a-56 d, the controls of coring knife 140 includenumbers visible on the exterior surface of its controls to indicate tothe user the sequence in which the controls are to be actuated. Insurgical use, the first control to be actuated is control lever 364 inthe form of a key. Turning or twisting of key 364 in the direction ofarrow 365 causes coring abutment to pivot from its initial position inFIG. 56 a to its next position in FIG. 56 b. This is done while coringabutment 145 is inside the heart cavity and the remainder of coringknife 154 is outside, on the other side of the heart wall. The secondcontrol to be actuated is release trigger 362 in the form of a pushbutton. Pressing down on push button 362, in the direction of arrow 363(FIG. 56 b), unlocks slide assembly 370 so that the user can take up anyslack between heart tissue 398 and coring abutment 145 (inside the heartcavity) and/or coring knife case 141 (outside the heart cavity). Takingup the slack is performed by reducing the longitudinal distance betweencoring abutment 145 and coring knife case 141, as shown from FIGS. 56b-56 c. The third control to be actuated is knob 385. Twisting of knob385 in the direction of arrow 382 (FIG. 56 c) causes coring blade 137 toextend out of coring knife case 141 toward coring abutment 145. Thecoring blade 137 cuts a circular hole through the portion of the heartwall 398 between coring knife case 141 and coring abutment 145.

Push button 362 is spring loaded and configured to be pressed down indirection 363 that is perpendicular or about perpendicular tolongitudinal axis 366. Push button 362 is connected to a ball detentmechanism within central shaft 372. When push button 362 is in itsnatural state (not pressed down), the ball detent mechanism engagesslide assembly 370 and prevents slide assembly 370 from inadvertentlysliding toward coring abutment 145. In particular, the ball detentmechanism engages one or more of holes 392 to prevent slide assembly 370from sliding freely on central shaft 372. When push button 362 is in itsactuated state (pressed down with the application of downward force onpush button), the ball detent mechanism disengages slide assembly 370,allowing slide assembly 370 to slide freely toward coring abutment 145.In particular, the ball detent mechanism disengages holes 392 to allowslide assembly 370 to slide freely on central shaft 372. When pushbutton 362 is released (upon removal of the downward force), a springacting on bush button 362 causes it to return to its natural state andthereby cause the ball detent mechanism to lock the slide assembly 370at its present longitudinal position. More specifically, the ball detentmechanism locks internal sleeve 386 and coring knife case 141 at theirpresent longitudinal position, and subsequent rotation of knob 385causes coring blade 137 to extend out of coring knife case 141.

Key socket 420 is secured to the rear end of central shaft 372 by pins422 (FIG. 56 a) passing through central shaft 372 and key socket 420.Key 364 is disposed within key socket 420 and is connected to controlarm 146 which extends into central shaft 372. The other end of controlarm 146 is attached to coring abutment 142. Control arm 142 is able toslide longitudinally within central shaft 372. As explained below,twisting of key 364 causes longitudinal movement of control arm 146,which in turn causes coring abutment 145 to pivot between the positionsshown in FIGS. 56 a and 56 b. The twist axis of key 364 is coaxial tolongitudinal axis 366 of coring knife 140. In other embodiments, thetwist axis of key 364 is offset from the longitudinal axis 366 and canbe parallel or non-parallel to longitudinal axis 366.

As shown in FIG. 57, key 364 includes paddle 424 attached to cylinder426. When coring knife 140 is assembled, paddle 424 extends out of keysocket 420 and is manipulated by the user to twist key 364. Cylinder 426is contained within key socket 420. Outer surface 428 of cylinder 426extends longitudinally and terminates at circular key edge 430. Key edge430 appears as a circle when viewed along longitudinal axis 366 ofcoring knife 140. Key edge 430 defines the free end of cylinder 426. Keyedge 430 has multiple segments that are uneven with each other. Key edge430 includes two top segments 432, ramp segments 434, and two bottomsegments 436. Top segments 432 are separated from each other by bottomsegments 436. Ramp segments 434 connect top segments 432 to bottomsegments 436. Top segments 432 form the outer-most tip of cylinder 426and longitudinally extend further away from paddle 424 than bottomsegments 436. In some embodiments, the difference in longitudinalposition between top segments 432 and bottom segments 436 defines thelongitudinal sliding distance of control arm 146 when key 364 isrotated.

As shown in FIGS. 58 a and 58 b, key socket 420 includes forward cavity440 and rear cavity 442 which are separated from each other by septumwall 445. When coring knife 140 is assembled, the rear end of centralshaft 372 (FIG. 56 d) is disposed within forward cavity 440, andcylinder 426 of key 364 is disposed within rear cavity 442. Centralshaft 372 is attached to key socket 420 so that it cannot rotate or movelongitudinally relative to key socket 420. Inner side surfaces 444 ofrear cavity 442 terminate at bottom end surface 446 of rear cavity 442.Bottom end surface 446 forms one side of septum wall 445.

Bottom end surface 446 includes multiple areas that are uneven with eachother. These uneven areas serve as bearing surfaces for key edge 430.When key 364 is twisted, contact between bottom end surface 446 of keysocket 420 and key edge 430 of key 364 causes control arm 146 to slidelongitudinally within central shaft 372 and thereby cause coringabutment 145 to pivot. The uneven areas of bottom end surface 446 are:top portion 448, two bottom portions 450, and ramp portions 452. Bottomportions 450 are located on opposite sides of top portion 448. Rampportions 452 connect top portion 448 to bottom portions 450. Top portion448 is located at the center of bottom end surface 446 andlongitudinally extends further away from coring abutment 145 (FIG. 56 d)than bottom portions 450. In some embodiments, the difference inlongitudinal position between top portion 448 and bottom portions 450defines the longitudinal sliding distance of control arm 146 when key364 is rotated.

As shown in FIG. 59 a, contours of bottom end surface 446 of key socket420 mate with or correspond to contours of key edge 430 of key 364. Whenkey 364 is in its initial position (as shown in FIGS. 59 a and 56 a),top segments 432 of key edge 430 face or make contact with bottomportions 450 of socket bottom end surface 446. Bottom segments 436 ofkey edge 430 face or make contact with top portion 448 of socket bottomend surface 446. When key 364 is twisted relative to key socket 420,ramp segments 434 of key edge 430 slide against ramp portions 452 ofsocket bottom end surface 446. As shown in FIG. 59 b, further twistingof key 364 causes top segments 432 of key edge 430 to slide up andagainst ramp portions 452 until top segments 432 rest against topportion 448. As a result, key 364 moves rearward and away from coringabutment 145, pulls control arm 146 in the same direction, and pivotscoring abutment 145. Control arm 146 and key 364 are longitudinallycoupled in a way that key 364 and control arm 146 move longitudinallytogether. Control arm 146 and key 364 are not rotationally coupled sothat control arm 146 does not twist when key 364 is twisted.

Contact between key 364 and the bottom end surface 446 of key socket 420is maintained by compression spring 460 within forward cavity 440 of keysocket 420. Compression spring 460 is compressed between bushing 462 oncontrol arm 146 and septum wall 445 of key socket 420. Bushing 462 is anintegral part of or fixedly attached to control arm 146. Thus,compression spring 460 causes control arm 146 to be biased in a forwardlongitudinal direction toward coring abutment 145. Since control arm 146is connected to key 364, compression spring 460 also causes key 364 tobe biased in a forward longitudinal direction against bottom end surface446 of key socket 420.

In the illustrated embodiment, abutment surface 414 (FIG. 56 a) is flat.In other embodiments, abutment surface 414 is not completely flat andincludes a raised central portion and tapered edges, such as shown inFIG. 55.

In FIGS. 60 a-60 c, another embodiment of slitting tool 300 is shown.The slitting tool of FIGS. 60 a-60 c has structural elements that arelabeled with the same reference numerals as those of FIGS. 52 a-52 c.Those structural elements have the same function as those described inconnection with FIGS. 52 a-52 c.

Referring to FIGS. 60 a-60 c, housing 302 includes forward housing 500and rear housing 502 which are held together by pins 504. Front segment506 of rear housing 502 is contained within forward housing 500. Pins504 pass through front segment 506 and forward housing 500. Frontsegment 506 includes wall 322 having an aperture sized to receiveforward end 324 of actuator 310. Spring 316 is coiled around middlesegment 508 of actuator 310 and is compressed between rear segment 510of actuator 310 and wall 322. Spring 316 keeps blade 326 housedcompletely within forward housing 500 until actuator 310 is pushed inthe direction of arrow 312. Pushing actuator 310 causes the tip of blade326 to protrude out of slit opening 314 and causes additionalcompression of spring 316. When actuator 310 is released by the user,spring 316 pushes rear segment 510 of actuator 310 so that blade 326retracts into forward housing 500.

Forward end 324 of actuator 310 is coupled to blade holder 512 which islocated on the opposite side of wall 322 as spring 316. Blade holder 512secures blade 326 to forward end 324 of actuator 310. Blade 526protrudes out of front end 514 of blade holder 512. Because blade holder512 is wider than the aperture of wall 322, blade holder 512 abuts wall322 and prevents forward end 324 of actuator 310 from being pulled byspring 316 into rear housing 502. When actuator 310 is pushed in thedirection of arrow 312, blade holder 512 and blade 326 move forwarduntil front end 514 abuts interior end surfaces 516 of forward housing500. Interior end surfaces 516 are located within forward housing 500and adjacent slit opening 314.

As shown in FIG. 60 b, interior end surfaces 516 include two surfaceswhich are at a non-zero angle relative to each other so as to form adepression having a tapered cross sectional shape. Forward end 514 ofblade holder 512 includes surfaces which are at a non-zero anglerelative to each other so as to form a bump having a tapered crosssectional shape. In some embodiment, the depression formed by interiorend surfaces 516 is configured to receive the bump on forward end 514 ofblade holder 512 so as to form a fluid seal behind slit opening 314 thatprevents blood within the heart from flowing into housing 302 when blade326 is pushed forward completely.

In some embodiments, blade holder 512 makes contact with and slidesagainst interior side surfaces 518 of forward housing 500 when actuator312 is pushed. In some embodiments, contact between blade holder 512 andinterior side surface 518 forms a fluid seal that prevents blood fromflowing into rear housing 502 after blade 326 is retracted into forwardhousing 500.

In FIGS. 60 a-60 c, slitting tool 300 has no blade seal and no wiper atfront end 304 of housing 302. In other embodiments, blade seal and wipershown in FIG. 52 c are incorporated into the slitting tool of FIGS. 60a-60 c.

Any elements described herein as singular can be pluralized (i.e.,anything described as “one” can be more than one). Attaching, coupling,and joining can be used interchangeably within this description. Anyspecies element of a genus element can have the characteristics orelements of any other species element of that genus. The above-describedconfigurations, elements or complete assemblies and methods and theirelements for carrying out the invention, and variations of aspects ofthe invention can be combined and modified with each other in anycombination.

1. A coring knife comprising: a coring blade including a circularcutting edge; a coring abutment located forward of the cutting edge; akey socket located to the rear of the coring blade, the key socketincluding a bearing surface; and a key connected to the coring abutmentand including a key edge in contact with the bearing surface, the keyconfigured to be moved relative the key socket, wherein when the key ismoved relative the key socket, the key edge slips against the bearingsurface and the key pivots the coring abutment relative to the coringblade.
 2. The coring knife of claim 1, further comprising a control armconnecting the coring abutment to the key, the control arm extendingthrough the coring blade and the key socket.
 3. The coring knife ofclaim 2, wherein the key is configured to be twisted about a twist axis,and wherein when the key is twisted, the key edge slips against thebearing surface and the key pivots the coring abutment relative to thecoring blade
 4. The coring knife of claim 3, wherein when the key istwisted, the control arm moves along a longitudinal axis that isparallel to the twist axis.
 5. The coring knife of claim 1, wherein thekey includes a cylinder having an outer surface that terminates at thekey edge.
 6. The coring knife of claim 5, wherein the key edge isdisposed within a rear cavity of the key socket.
 7. The coring knife ofclaim 6, wherein the key socket includes a forward cavity and a septumwall separating the forward cavity from the rear cavity, and the bearingsurface forms a side of the of the wall within the rear cavity.
 8. Thecoring knife of claim 6, wherein the coring blade is mounted over acentral shaft extending out of the forward cavity of the key socket, thecoring blade is configured to be rotated around the central shaft, andwherein when the coring blade is rotated, the coring blade moves towardthe coring abutment.
 9. The coring knife of claim 6, wherein the coringblade is carried on an internal sleeve, the internal sleeve is carriedon a central shaft extending out of the forward cavity of the keysocket, the internal sleeve is configured to slide relative the centralshaft in a direction toward the coring abutment, the coring blade isconfigured to be rotate relative the internal sleeve, and wherein whenthe coring blade is rotated, the coring blade moves toward the coringabutment.
 10. The coring knife of claim 1, further comprising a coringknife case configured to be moved away from the key socket, wherein thecoring blade is movable into and out of the coring knife case.
 11. Thecoring knife of claim 10, wherein the coring blade is configured to moveout of the coring knife case by rotating the coring blade relative tothe coring knife case.
 12. The coring knife of claim 10, furthercomprising an control sleeve attached to the coring blade, the controlsleeve having a helical slot that extends into the coring knife case,wherein the coring knife case includes a guide peg that protrudes intothe helical slot, and wherein rotation of the control sleeve causes thecoring blade to move out of the coring knife case.
 13. The coring knifeof claim 12, further comprising an internal sleeve and a central shaft,the central shaft fixedly attached to the key socket and extending intothe internal sleeve, the internal sleeve carrying the control sleeve,the coring blade, and the coring knife case, and wherein the internalsleeve is configured to be selectively positioned and locked at any oneof a plurality of locations on the central shaft.
 14. A coring knifecomprising: a coring blade including a cylindrical wall defining acircular cutting edge and a hollow interior; a coring abutment; a coringknife case containing the coring blade, the coring blade configured tobe extended out of the coring knife case and toward the coring abutment;and a key coupled to the coring abutment by a control arm extending intothe coring blade, the key disposed within a key socket and configured tobe rotated relative to the key socket, wherein when the key is rotatedrelative the key socket, the key pulls the control arm in a manner thatpivots the coring abutment relative to the coring blade.
 15. The coringknife of claim 14, wherein the coring knife case includes a stop featureconfigured to fit in an alignment feature of a separate device foraligning the coring knife prior to extension of the coring blade out ofthe coring knife case.
 16. The coring knife of claim 14, wherein thecoring knife case is configured to be selectively positioned and lockedat any one of a plurality of locations between the key socket and thecoring abutment prior to extension of the coring blade out of the coringknife case.
 17. The coring knife of claim 16, further comprising adetent mechanism that selectively locks and unlocks the coring knifecase at any one of the plurality of locations between the key socket andthe coring abutment.
 18. A coring knife comprising: a coring abutment akey connected to the coring abutment; and a slide assembly disposedbetween the key and the coring abutment, the slide assembly including acoring blade with a circular cutting edge and a coring knife casecontaining the coring blade, the coring blade configured to extend outof the coring knife case, the coring knife case configured to beselectively positioned and locked at any one of a plurality of locationsbetween the key and the coring abutment prior to extension of the coringblade out of the coring knife case.
 19. The coring knife of claim 18,wherein the coring knife case includes a stop feature configured to fitin an alignment feature of a separate device for aligning the coringknife prior to extension of the coring blade out of the coring knifecase
 20. The coring knife of claim 18, further comprising a detentmechanism that selectively locks and unlocks the coring knife case atany one of the plurality of locations between the key and the coringabutment.